Stroke Patients With Faster Core Growth Have Greater Benefit From Endovascular Therapy

Stroke ◽  
2021 ◽  
Author(s):  
Longting Lin ◽  
Hao Zhang ◽  
Chushuang Chen ◽  
Andrew Bivard ◽  
Kenneth Butcher ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Growth Rate ◽  
Clinical Outcome ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Stroke Onset ◽  
Stroke Patients ◽  
Good Clinical Outcome ◽  
Perfusion Computed Tomography ◽  
Infarction Volume

Background and Purpose: This study aimed to explore whether the therapeutic benefit of endovascular thrombectomy (EVT) was mediated by core growth rate. Methods: This retrospective cohort study identified acute ischemic stroke patients with large vessel occlusion and receiving reperfusion treatment, either EVT or intravenous thrombolysis (IVT), within 4.5 hours of stroke onset. Patients were divided into 2 groups: EVT versus IVT only patients (who had no access to EVT). Core growth rate was estimated by the acute core volume on perfusion computed tomography divided by the time from stroke onset to perfusion computed tomography. The primary clinical outcome was good outcome defined by 3-month modified Rankin Scale score of 0–2. Tissue outcome was the final infarction volume. Results: A total of 806 patients were included, 429 in the EVT group (recanalization rate of 61.6%) and 377 in the IVT only group (recanalization rate of 44.7%). The treatment effect of EVT versus IVT only was mediated by core growth rate, showing a significant interaction between EVT treatment and core growth rate in predicting good clinical outcome (interaction odds ratio=1.03 [1.01–1.05], P =0.007) and final infarct volume (interaction odds ratio=−0.44 [−0.87 to −0.01], P =0.047). For patients with fast core growth of >25 mL/h, EVT treatment (compared with IVT only) increased the odds of good clinical outcome (adjusted odds ratio=3.62 [1.21–10.76], P =0.021) and resulted in smaller final infarction volume (37.5 versus 73.9 mL, P =0.012). For patients with slow core growth of <15 mL/h, there were no significant differences between the EVT and the IVT only group in either good clinical outcome (adjusted odds ratio=1.44 [0.97–2.14], P =0.070) or final infarction volume (22.6 versus 21.9 mL, P =0.551). Conclusions: Fast core growth was associated with greater benefit from EVT compared with IVT in the early <4.5-hour time window.

scholarly journals Thrombus Migration and Fragmentation After Intravenous Alteplase Treatment

Stroke ◽  
2021 ◽  
Vol 52 (1) ◽  
pp. 203-212
Author(s):  
Tomoyuki Ohara ◽  
Bijoy K. Menon ◽  
Fahad S. Al-Ajlan ◽  
MacKenzie Horn ◽  
Mohamed Najm ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Carotid Artery ◽  
Clinical Outcome ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Internal Carotid ◽  
Artery Occlusion ◽  
Intravenous Alteplase ◽  
Over Time

Background and Purpose: There is interest in what happens over time to the thrombus after intravenous alteplase. We study the effect of alteplase on thrombus structure and its impact on clinical outcome in patients with acute stroke. Methods: Intravenous alteplase treated stroke patients with intracranial internal carotid artery or middle cerebral artery occlusion identified on baseline computed tomography angiography and with follow-up vascular imaging (computed tomography angiography or first run of angiography before endovascular therapy) were enrolled from INTERRSeCT study (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography). Thrombus movement after intravenous alteplase was classified into complete recanalization, thrombus migration, thrombus fragmentation, and no change. Thrombus migration was diagnosed when occlusion site moved distally and graded according to degrees of thrombus movement (grade 0–3). Thrombus fragmentation was diagnosed when a new distal occlusion in addition to the primary occlusion was identified on follow-up imaging. The association between thrombus movement and clinical outcome was also evaluated. Results: Among 427 patients in this study, thrombus movement was seen in 54% with a median time of 123 minutes from alteplase administration to follow-up imaging, and sub-classified as marked (thrombus migration grade 2–3 + complete recanalization; 27%) and mild to moderate thrombus movement (thrombus fragmentation + thrombus migration grade 0–1; 27%). In patients with proximal M1/internal carotid artery occlusion, marked thrombus movement was associated with a higher rate of good outcome (90-day modified Rankin Scale, 0–2) compared with mild to moderate movement (52% versus 27%; adjusted odds ratio, 5.64 [95% CI, 1.72–20.10]). No difference was seen in outcomes between mild to moderate thrombus movement and no change. In M1 distal/M2 occlusion, marked thrombus movement was associated with improved 90-day good outcome compared with no change (70% versus 56%; adjusted odds ratio, 2.54 [95% CI, 1.21–5.51]). Conclusions: Early thrombus movement is common after intravenous alteplase. Marked thrombus migration leads to good clinical outcomes. Thrombus dynamics over time should be further evaluated in clinical trials of acute reperfusion therapy.

scholarly journals Blood Pressure and Early Clinical Outcome Among Acute Ischemic Stroke Patients

2011 ◽  
Vol 38 (2) ◽  
pp. 225-229 ◽  
Author(s):  
Jintao Zhang ◽  
Ying Peng ◽  
Huanqing Fan ◽  
Mei Chen ◽  
Tan Xu ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Resonance Imaging ◽  
Stroke Patients ◽  
Short Term ◽  
Tomography Scan

ABSTRACT:Objectives:The association between blood pressure (BP) and short-term clinical outcome of acute ischemic stroke is inconclusive. We investigated the association between BP in the first 72 hours following admission and death in-hospital and neurologic deficiency at discharge among patients with acute ischemic stroke.Methods:A total of 2675 acute ischemic stroke patients confirmed by a computed tomography scan or magnetic resonance imaging were included in the present study. Blood pressure in the first 72 hours after admission and other study variables were collected for all ischemic stroke patients. Neurological functions National Institute of Health Stroke Scale (NIHSS) were evaluated by trained neurologists at discharge. The study outcome was defined as death in-hospital and neurologic deficiency (NIHSS≥10) at discharge.Results:Systolic and diastolic BP were significantly and positively associated with odds of study outcome in acute ischemic stroke. For example, compared to those with a systolic BP<140 mmHg, multiple-adjusted odds ratio (95% confidence interval) of study outcome was 3.29(1.22, 8.90) among participants with systolic BP of 180-219 mmHg,P<0.05; compared to those with a diastolic BP<90 mmHg, multiple-adjusted odds ratio of study outcome was 7.05(1.32, 37.57) among participants with diastolic BP ≥ 120 mmHg,P<0.05.Conclusion:Systolic BP≥180 and diastolic BP≥120 were significantly and positively associated with death in-hospital or neurologic deficiency at discharge among patients with acute ischemic stroke.

scholarly journals Good Clinical Outcome Decreases With Number of Retrieval Attempts in Stroke Thrombectomy

Stroke ◽  
2021 ◽  
Vol 52 (2) ◽  
pp. 482-490
Author(s):  
Fabian Flottmann ◽  
Caspar Brekenfeld ◽  
Gabriel Broocks ◽  
Hannes Leischner ◽  
Rosalie McDonough ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Cerebral Infarction ◽  
Scale Score ◽  
Endovascular Therapy ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Functional Independence ◽  
Good Clinical Outcome ◽  
Anterior Circulation ◽  
Vessel Occlusion

Background and Purpose: Endovascular therapy is the standard of care in the treatment of acute ischemic stroke due to large-vessel occlusion. Often, more than one retrieval attempt is needed to achieve reperfusion. We aimed to quantify the influence of endovascular therapy on clinical outcome depending on the number of retrievals needed for successful reperfusion in a large multi-center cohort. Methods: For this observational cohort study, 2611 patients from the prospective German Stroke Registry included between June 2015 and April 2018 were analyzed. Patients who received endovascular therapy for acute anterior circulation stroke with known admission National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score, final Thrombolysis in Cerebral Infarction score, and number of retrievals were included. Successful reperfusion was defined as a Thrombolysis in Cerebral Infarction score of 2b or 3. The primary outcome was defined as functional independence (modified Rankin Scale score of 0–2) at day 90. Multivariate mixed-effects models were used to adjust for cluster effects of the participating centers and confounders. Results: The inclusion criteria were met by 1225 patients. The odds of good clinical outcome decreased with every retrieval attempt required for successful reperfusion: the first retrieval had the highest odds of good clinical outcome (adjusted odds ratio, 6.45 [95% CI, 4.0–10.4]), followed by the second attempt (adjusted odds ratio, 4.56 [95% CI, 2.7–7.7]), and finally the third (adjusted odds ratio, 3.16 [95% CI, 1.8–5.6]). Conclusions: Successful reperfusion within the first 3 retrieval attempts is associated with improved clinical outcome compared with patients without reperfusion. We conclude that at least 3 retrieval attempts should be performed in endovascular therapy of anterior circulation strokes. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03356392.

Abstract W P48: Flair Vessel Hyper-intensities Could Predict Target Mismatch Signs in Acute Stroke Patients

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Manabu Inoue ◽  
Michael Mlynash ◽  
Carlo W Cerada ◽  
Nishant K Mishra ◽  
Soren Christensen ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Clinical Outcomes ◽  
Pooled Analysis ◽  
Stroke Patients ◽  
Good Clinical Outcome ◽  
Kappa Score ◽  
Early Reperfusion ◽  
Diffusion Weighted Images ◽  
Fluid Attenuated Inversion Recovery

Background and purpose: Fluid-attenuated inversion recovery (FLAIR) vessel hyper-intensities (FVH) have been hypothesized to have a positive correlation with good collaterals and more favorable clinical outcomes in acute stroke patients. We assessed if FVH predict the Target mismatch profile (TMM) and clinical outcomes in the DEFUSE studies. Methods: Patients with technically adequate baseline diffusion weighted images (DWI), perfusion images (PWI), and FLAIR images were included in this pooled analysis of the DEFUSE 1 and 2 studies. The FVH sign was defined as visible hyper-intense vessels on FLAIR images and assessed at basal ganglia levels by two independent raters. Clinical outcomes were assessed using modified Rankin Scale (mRS) at 90 days. The Target mismatch profile was based on baseline DWI and PWI volumes using automated software (RAPID). Results: Seventy seven patients met the inclusion criteria. Median time (IQR) from symptom onset to baseline MRI was 4.6 hours (3.9 - 5.4) and median (IQR) DWI lesion was 13.1 (5.0 - 32.0) ml. Of these, 66 patients (86%) had the FVH sign. Kappa score for inter-rater agreement was 0.621 (95CI: 0.33 - 0.91). Seventy (74%) cases with FVH had TMM profile vs. 33% of No FVH patients (p=0.023). Good clinical outcome (mRS 0-2) did not differ (50% with FVH vs. 73% without FVH, p=0.203). Only 38% of the patients with FVH had good angiographic collaterals and the rate of early reperfusion did not differ (45% with FVH vs. 25% without FVH, p=0.45). Conclusions: FVH is common in acute stroke patients (86%) and is associated with the Target Mismatch profile. However, FVH was not associated with favorable angiographic collaterals, good clinical outcome or early reperfusion in the DEFUSE 1 and 2 cohorts.

Abstract WP148: Functional Independence Score of Acute Stroke Patients Can Predict Favorable Clinical Outcome at 3 Months After Stroke Onset

Stroke ◽  
2018 ◽  
Vol 49 (Suppl_1) ◽  
Author(s):  
Takashi Johno ◽  
Hiroyuki Kawano ◽  
Masataka Torii ◽  
Hiroshi Kamiyama ◽  
Tatsuo Amano ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Functional Independence ◽  
Stroke Onset ◽  
Stroke Patients ◽  
Favorable Clinical Outcome

scholarly journals Metabolome of Cerebral Thrombi Reveals an Association between High Glycemia at Stroke Onset and Good Clinical Outcome

Metabolites ◽  
2020 ◽  
Vol 10 (12) ◽  
pp. 483
Author(s):  
Laurent Suissa ◽  
Jean-Marie Guigonis ◽  
Fanny Graslin ◽  
Emilie Doche ◽  
Ophélie Osman ◽  
...  
Keyword(s):  
Blood Glucose ◽  
Discriminant Analysis ◽  
Clinical Outcome ◽  
Blood Glucose Level ◽  
Glucose Level ◽  
Area Under The Curve ◽  
Stroke Onset ◽  
Stroke Patients ◽  
High Blood Glucose ◽  
High Blood Glucose Level

Despite the fact that glucose is the main fuel of the brain, hyperglycemia at hospital admission is generally associated with a poor functional outcome in stroke patients. This paradox may be explained by the lack of information about the blood glucose level at stroke onset. Here, we analyzed the metabolome of blood cells entrapped in cerebral thrombi to gain insight into their metabolism at stroke onset. Fourty-one consecutive stroke patients completely recanalized by mechanical thrombectomy within 6 h were included. The metabolome of retrieved thrombi was analyzed by liquid chromatography tandem with mass spectrometry. Discriminant Analysis (sparse Partial Least Squares Discriminant Analysis (sPLS-DA)) was performed to identify classification models and significant associated features of favorable clinical outcome at 3 months (modified Rankin Scale (mRS) < 2). sPLS-DA of the metabolomes of cerebral thrombi discriminated between stroke patients with a favorable or poor clinical outcome (Area Under the Curve (AUC) = 0.992 (0.931–1)). In addition, our results revealed that high sorbitol and glucose levels in the thrombi positively correlated with favorable clinical outcomes. Sorbitol, a short-term glycemic index reflecting a high blood glucose level at stroke onset, was found to be an independent predictor of good outcome (AUC = 0.908 (0.807–0.995)). This study demonstrates that a high blood glucose level at stroke onset is beneficial to the clinical outcome of the patient.

scholarly journals DWI-pc-ASPECT score in basilar artery occlusion: is 6 points or less always indicative of a bad outcome?

2019 ◽  
Vol 25 (4) ◽  
pp. 371-379 ◽  
Author(s):  
Joong-Goo Kim ◽  
Dongwhane Lee ◽  
Jay Chol Choi ◽  
Yunsun Song ◽  
Deok Hee Lee ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Confidence Interval ◽  
Odds Ratio ◽  
Arterial Occlusion ◽  
Reperfusion Therapy ◽  
Basilar Artery Occlusion ◽  
Poor Clinical Outcome ◽  
Good Clinical Outcome ◽  
Outcome Group ◽  
Initial Symptoms

Background and purpose The prognosis of patients with acute basilar arterial occlusion after endovascular reperfusion therapy with diffusion-weighted imaging – posterior circulation–Alberta Stroke Program Early Computed Tomography Score (DWI-pc-ASPECTS) of 6 or less remains unclear. We aimed to assess the characteristics and prognosis of endovascular reperfusion therapy in patients with acute basilar arterial occlusion and DWI-pc-ASPECTS of 6 or less. Methods We analysed data collected from 1 January 2012 to 31 January 2018 in a prospective neuro-interventional registry of consecutive patients treated with endovascular reperfusion therapy. Clinical and imaging data on patients with DWI-pc-ASPECTS of 6 or less who underwent endovascular reperfusion therapy for acute basilar arterial occlusion were collected for this study. A good clinical outcome was defined as a modified Rankin scale of 2 or less at 90 days. Results Forty-five acute basilar arterial occlusion patients with DWI-pc-ASPECTS of 6 or less were included. Among them, 11 (24.4%) patients had a good clinical outcome at 90 days. Patients with a good clinical outcome had less severe neurological symptoms at presentation (National Institutes of Health Stroke Scale (NIHSS) 19.0 (12.0–25.0) vs. 8.0 (6.0–11.5); P = 0.003) and were younger (72.5 years (57.0–80.0 years) vs. 63.0 years (55.5–69.0 years), P = 0.096) than those with a poor clinical outcome. The symptomatic intracranial haemorrhage rate was significantly higher in the poor clinical outcome group (13 (38.2%)) than in the good clinical outcome group (0 (0.0%)) ( P = 0.045). In particular, in patients aged over 70 years, a favourable outcome was low (18 (52.9%) vs. 1 (9.1%); P = 0.027) even after successful recanalisation. In a multivariate model, a low initial NIHSS score (odds ratio 1.21; 95% confidence interval 1.07–1.44; P = 0.0093) and age over 70 years (odds ratio 15.27; 95% confidence interval 1.85–379.79; P = 0.0321) were independent predictors of poor clinical outcome. Conclusions Even with DWI-pc-ASPECTS of 6 or less, good clinical outcome can be achieved after endovascular reperfusion therapy. Relatively mild initial symptoms and younger age can predict a better outcome in acute basilar arterial occlusion patients with DWI-pc-ASPECTS of 6 or less.

scholarly journals Treatment and Outcome in Stroke Patients With Acute M2 Occlusion and Minor Neurological Deficits

Stroke ◽  
2021 ◽  
Author(s):  
Tomas Dobrocky ◽  
Eike I. Piechowiak ◽  
Bastian Volbers ◽  
Nedelina Slavova ◽  
Johannes Kaesmacher ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Scale Score ◽  
Cerebral Artery ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
National Institutes Of Health ◽  
Neurological Deficits ◽  
Minor Stroke ◽  
Modified Rankin Scale ◽  
Stroke Patients

Background and Purpose: Treatment in stroke patients with M2 segment occlusion of the middle cerebral artery presenting with mild neurological deficits is a matter of debate. The main purpose was to compare the outcome in patients with a minor stroke and a M2 occlusion. Methods: Consecutive intravenous thrombolysis (IVT) eligible patients admitted to the Bernese stroke center between January 2005 and January 2020 with acute occlusion of the M2 segment and National Institutes of Health Stroke Scale score ≤5 were included. Outcome was compared between IVT only versus endovascular therapy (EVT) including intra-arterial thrombolysis and mechanical thrombectomy (MT; ±IVT) and between IVT only versus MT only. Results: Among 169 patients (38.5% women, median age 70.2 years), 84 (49.7%) received IVT only and 85 (50.3%) EVT (±IVT), the latter including 39 (45.9%) treated with MT only. Groups were similar in sex, age, vascular risk factors, event cause, or preevent independency. Compared with IVT only, there was no difference in favorable outcome (modified Rankin Scale score, 0−2) for EVT (adjusted odds ratio, 0.96; adjusted P =0.935) or for MT only (adjusted odds ratio, 1.12; adjusted P =0.547) groups. Considering only patients treated after 2015, there was a significantly better 3-month modified Rankin Scale shift (adjusted P =0.032) in the EVT compared with the IVT only group. Conclusions: Our study demonstrates similar effectiveness of IVT only versus EVT (±IVT), and of IVT only versus MT only in patients with peripheral middle cerebral artery occlusions and minor neurological deficits and indicates a possible benefit of EVT considering only patients treated after 2015. There is an unmet need for randomized controlled trials in this stroke field, including imaging parameters, and more sophisticated evaluation of National Institutes of Health Stroke Scale score subitems, neurocognition, and quality of life neglected by the standard outcome scales such as modified Rankin Scale and National Institutes of Health Stroke Scale score.

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