Should Tenecteplase be Given in Clinical Practice for Acute Ischemic Stroke Thrombolysis?

Introduction: Outcomes after endovascular treatment (EVT) for acute ischemic stroke are highly time dependent, but whether active reduction of time to treatment leads to better outcome has not been demonstrated. We compared data of the two subsequent MR CLEAN Registry cohorts, comprising all patients in the Netherlands who had EVT for acute ischemic stroke from 2014-2017, for a trend in time to treatment and its association with outcome. Methods: We compared workflow, successful reperfusion (eTICI 2B-3), NIHSS at 24h, functional outcome (mRS) at 90 days, occurrence of symptomatic intracranial hemorrhage (sICH) and mortality in patients with ischemic stroke and a proximal intracranial occlusion in the anterior circulation included in the second cohort of the Registry (June 2016-November 2017; n = 1779) to those in patients included in the first cohort (March 2014-June 2016; n = 1526) using logistic regression. Results: Baseline NIHSS was 16 in both cohorts. Times from onset-to-groin and onset-to-reperfusion were shorter in the second cohort than in the first (185 versus 210 minutes; p<0.01 and 238 versus 270 minutes; p<0.01, respectively) (Figure 1). Successful reperfusion was achieved more often in the second than in the first cohort (72% versus 58%; p<0.01). Rates of sICH and mortality did not differ (5.9% versus 5.7%; p=0.94 and 29% versus 29%; p=0.60). However, follow-up NIHSS was lower (median 10 versus 11; p<0.001) and more patients achieved functional independence at 90 days (42.6% versus 38.9%; p = 0.012) in the second cohort (Figure 1). In a logistic regression model, the difference in good outcome between the two cohorts (aOR 1.27; 95%CI 1.08-1.50) was reduced after additional adjustment for time to reperfusion (aOR 1.15; 95%CI 0.96-1.36) as well as successful reperfusion (aOR 1.16; 95%CI 0.95-1.41). Discussion: Our data show that outcomes after EVT in routine clinical practice are improving, likely attributable to improved workflow and experience.

Download Full-text

Etiologic Workup in Cases of Cryptogenic Stroke

Stroke ◽

10.1161/strokeaha.119.027123 ◽

2020 ◽

Vol 51 (5) ◽

pp. 1419-1427 ◽

Cited By ~ 5

Author(s):

Naoimh E. McMahon ◽

Munirah Bangee ◽

Valerio Benedetto ◽

Emma P. Bray ◽

Rachel F. Georgiou ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Practice ◽

Secondary Prevention ◽

Acute Ischemic Stroke ◽

Clinical Practice Guidelines ◽

Practice Guidelines ◽

Cryptogenic Stroke ◽

Unique Identifier ◽

Missed Opportunities ◽

Consensus Statements

Background and Purpose— Identifying the etiology of acute ischemic stroke is essential for effective secondary prevention. However, in at least one third of ischemic strokes, existing investigative protocols fail to determine the underlying cause. Establishing etiology is complicated by variation in clinical practice, often reflecting preferences of treating clinicians and variable availability of investigative techniques. In this review, we systematically assess the extent to which there exists consensus, disagreement, and gaps in clinical practice recommendations on etiologic workup in acute ischemic stroke. Methods— We identified clinical practice guidelines/consensus statements through searches of 4 electronic databases and hand-searching of websites/reference lists. Two reviewers independently assessed reports for eligibility. We extracted data on report characteristics and recommendations relating to etiologic workup in acute ischemic stroke and in cases of cryptogenic stroke. Quality was assessed using the AGREE II tool (Appraisal of Guidelines for Research & Evaluation). Recommendations were synthesized according to a published algorithm for diagnostic evaluation in cryptogenic stroke. Results— We retrieved 16 clinical practice guidelines and 7 consensus statements addressing acute stroke management (n=12), atrial fibrillation (n=5), imaging (n=5), and secondary prevention (n=1). Five reports were of overall high quality. For all patients, guidelines recommended routine brain imaging, noninvasive vascular imaging, a 12-lead ECG, and routine blood tests/laboratory investigations. Additionally, ECG monitoring (>24 hours) was recommended for patients with suspected embolic stroke and echocardiography for patients with suspected cardiac source. Three reports recommended investigations for rarer causes of stroke. None of the reports provided guidance on the extent of investigation needed before classifying a stroke as cryptogenic. Conclusions— While consensus exists surrounding standard etiologic workup, there is little agreement on more advanced investigations for rarer causes of acute ischemic stroke. This gap in guidance, and in the underpinning evidence, demonstrates missed opportunities to better understand and protect against ongoing stroke risk. Registration— URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42019127822.

Download Full-text

Association Between Time to Treatment With Endovascular Reperfusion Therapy and Outcomes in Patients With Acute Ischemic Stroke Treated in Clinical Practice

JAMA ◽

10.1001/jama.2019.8286 ◽

2019 ◽

Vol 322 (3) ◽

pp. 252 ◽

Cited By ~ 27

Author(s):

Reza Jahan ◽

Jeffrey L. Saver ◽

Lee H. Schwamm ◽

Gregg C. Fonarow ◽

Li Liang ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Practice ◽

Acute Ischemic Stroke ◽

Reperfusion Therapy ◽

Time To Treatment

Download Full-text

North American Solitaire Stent Retriever Acute Stroke registry: post-marketing revascularization and clinical outcome results

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2013-010895.rep ◽

2018 ◽

Vol 10 (Suppl 1) ◽

pp. i45-i49 ◽

Cited By ~ 1

Author(s):

Osama O Zaidat ◽

Alicia C Castonguay ◽

Rishi Gupta ◽

Chung-Huan J Sun ◽

Coleman Martin ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Practice ◽

Clinical Outcome ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

North American ◽

Outcome Data ◽

Stent Retriever ◽

Post Marketing ◽

Solitaire Fr

BackgroundLimited post-marketing data exist on the use of the Solitaire FR device in clinical practice. The North American Solitaire Stent Retriever Acute Stroke (NASA) registry aimed to assess the real world performance of the Solitaire FR device in contrast with the results from the SWIFT (Solitaire with the Intention for Thrombectomy) and TREVO 2 (Trevo versus Merci retrievers for thrombectomy revascularization of large vessel occlusions in acute ischemic stroke) trials.MethodsThe investigator initiated NASA registry recruited North American sites to submit retrospective angiographic and clinical outcome data on consecutive acute ischemic stroke (AIS) patients treated with the Solitaire FR between March 2012 and February 2013. The primary outcome was a Thrombolysis in Myocardial Ischemia (TIMI) score of ≥2 or a Treatment in Cerebral Infarction (TICI) score of ≥2a. Secondary outcomes were 90 day modified Rankin Scale (mRS) score, mortality, and symptomatic intracranial hemorrhage.Results354 patients underwent treatment for AIS using the Solitaire FR device in 24 centers. Mean time from onset to groin puncture was 363.4±239 min, mean fluoroscopy time was 32.9±25.7 min, and mean procedure time was 100.9±57.8 min. Recanalization outcome: TIMI ≥2 rate of 83.3% (315/354) and TICI ≥2a rate of 87.5% (310/354) compared with the operator reported TIMI ≥2 rate of 83% in SWIFT and TICI ≥2a rate of 85% in TREVO 2. Clinical outcome: 42% (132/315) of NASA patients demonstrated a 90 day mRS ≤2 compared with 37% (SWIFT) and 40% (TREVO 2). 90 day mortality was 30.2% (95/315) versus 17.2% (SWIFT) and 29% (TREVO 2).ConclusionsThe NASA registry demonstrated that the Solitaire FR device performance in clinical practice is comparable with the SWIFT and TREVO 2 trial results.

Download Full-text

Thrombectomy of calcified emboli in stroke. Does histology of thrombi influence the effectiveness of thrombectomy?

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013226 ◽

2017 ◽

Vol 10 (4) ◽

pp. 345-350 ◽

Cited By ~ 32

Author(s):

Tomas Dobrocky ◽

Eike Piechowiak ◽

Alessandro Cianfoni ◽

Felix Zibold ◽

Luca Roccatagliata ◽

...

Keyword(s):

Mechanical Properties ◽

Ischemic Stroke ◽

Clinical Practice ◽

Adverse Events ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Stent Retriever ◽

Complication Rates ◽

Peripheral Vessel ◽

Stent Retrievers

Background and purposeThrombus composition has been postulated to affect the success of endovascular therapy. Calcified clots are composed of large amounts of calcium phosphate which influences their mechanical properties and may serve as a model for testing this hypothesis. The aim of this study was to evaluate the recanalization and complication rates of calcified thromboemboli in patients with acute ischemic stroke who underwent thrombectomy.Material and methodsA retrospective analysis was performed of all calcified intracranial thromboemboli in patients suffering an acute ischemic stroke, referred for endovascular therapy at two centers between January 2013 and July 2016.ResultsEight patients with a calcified intracranial clot underwent stent retriever thrombectomy (five women; mean age 80 years). Mean clot attenuation was 305 HU (range 150–640 HU). Successful reperfusion defined, as Thrombolysis in Cerebral Infarction grade 2b–3 was achieved in only one patient (12.5%). Two periprocedural adverse events occurred: one peripheral vessel perforation which was coiled and one inadvertent stent retriever detachment due to fracture of the stent retriever wire.ConclusionStent retriever thrombectomy of calcified thromboemboli seems less effective than with other types of clots. Different mechanical properties of calcified clots may render them stiffer and less accessible for stent retrievers. When faced with a calcified intracranial thromboembolus in clinical practice, a more contained approach may be warranted in view of low recanalization rates, and the potential for periprocedural adverse events.

Download Full-text

Endovascular therapy of acute ischemic stroke in clinical practice

Journal of the Neurological Sciences ◽

10.1016/j.jns.2017.08.2800 ◽

2017 ◽

Vol 381 ◽

pp. 993

Author(s):

E. Scharf ◽

T. Chakraborty ◽

A. Ail ◽

J. Klaas ◽

W. Brinjikji ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Practice ◽

Acute Ischemic Stroke ◽

Endovascular Therapy

Download Full-text

Use of heparinized saline flush during endovascular thrombectomy for acute ischemic stroke; a survey of clinical practice in the Netherlands

CVIR Endovascular ◽

10.1186/s42155-021-00264-0 ◽

2021 ◽

Vol 4 (1) ◽

Author(s):

Faysal Benali ◽

Christiaan van der Leij ◽

Julie Staals ◽

Wim H. van Zwam

Keyword(s):

Ischemic Stroke ◽

Clinical Practice ◽

The Netherlands ◽

Research And Development ◽

Acute Ischemic Stroke ◽

Future Research ◽

Heparin Dose ◽

Endovascular Thrombectomy ◽

Heparinized Saline ◽

Relevant Variables

Abstract Background and introduction Information about optimal use of heparin in flush fluids during endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) is lacking. Variables that determine total heparin dose entering the patient by flush fluids are mostly unknown. We aim to provide insight in these unknown but highly relevant variables. Methods and results We performed a survey including all Dutch interventionists performing EVT (n = 79) collecting data on used concentration of heparin in infusion bags, number of infusion bags connected, timing of connecting the flush line and the dripping rate (ml/sec). We calculated potential heparin dose entering the patient per hour through flush fluids (IU/h). Twenty-eight interventionists (35%) representing 17 Dutch stroke centers completed the survey. Eight interventionists responded not to add any heparin to flush fluids (18%). The highest amount of heparin entering the patients was 13,500 IU/h, reported by 2 interventionists from the same center (4%). Conclusions We provide insight in the use of heparinized flush during EVT in the Netherlands. Total amounts of heparin administered via flush fluids may go up to 13,500 IU/h. With this paper we intend to set a starting for future research and development of guidelines on the use of heparinized flush fluids during EVT for AIS.

Download Full-text