scholarly journals Evolution of the stroke paradigm: A review of delayed recanalization

2020 ◽  
pp. 0271678X2097886
Author(s):  
Richard Camara ◽  
Nathanael Matei ◽  
John H Zhang
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Case Studies ◽  
Symptom Onset ◽  
Time Window ◽  
Extended Time ◽  
Time Points ◽  
Modern Imaging ◽  
Current Guidelines ◽  
Pathophysiologic Mechanisms

While the time window for reperfusion after ischemic stroke continues to increase, many patients are not candidates for reperfusion under current guidelines that allow for reperfusion within 24 h after last known well time; however, many case studies report favorable outcomes beyond 24 h after symptom onset for both spontaneous and medically induced recanalization. Furthermore, modern imaging allows for identification of penumbra at extended time points, and reperfusion risk factors and complications are becoming better understood. Taken together, continued urgency exists to better understand the pathophysiologic mechanisms and ideal setting of delayed recanalization beyond 24 h after onset of ischemia.

Abstract TP52: Endovascular Therapy in Patients Over 80 Years of Age With Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Janhavi M Modak ◽  
Syed Daniyal Asad ◽  
Jussie Lima ◽  
Amre Nouh ◽  
Ilene Staff ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Time Window ◽  
Extended Time ◽  
Stroke Patients ◽  
Stroke Outcomes ◽  
Stroke Treatment ◽  
Group A ◽  
Group B

Introduction: Acute ischemic stroke treatment has undergone a paradigm shift, with patients being treated in the extended time window (6-24 hours post symptom onset). The purpose of this study is to assess outcomes in stroke patients above 80 years of age undergoing endovascular treatment (EVT) in the extended time window. Methods: Acute ischemic stroke patients presenting to Hartford Hospital between January 2017 to June 2019 were considered for the study. Stroke outcomes in patients above 80 years of age with anterior circulation ischemic strokes presenting in the extended time window (Group A, n=30) were compared to a younger cohort of patients below 80 years (Group B, n=31). Patients over 80 years treated in the traditional time window (within 6 hours of symptom onset) served as a second set of controls (Group C, n=40). Statistical analysis was performed with a significance level of 0.05 Results: For angiographic results, there were no statistically significant differences in terms of good outcomes (TICI 2b-3) among patients of Group A, when compared to Groups B or C (p>0.05). For the endovascular procedures, no significant differences were noted in the total fluoroscopy time (Median Group A 44.05, Group B 38.1, Group C 35.25 min), total intra-procedure time (Median Group A 144, Group B 143, Group C 126 min) or total radiation exposure (Median Group A 8308, Group B 8960, Group C 8318 uGy-m 2 ). For stroke outcomes, a good clinical outcome was defined as modified Rankin score of 0-2 at discharge. Significantly better outcomes were noted in the younger patients in Group B - 35.4%, when compared to 13.3% in Group A (p=0.03). Comparative outcomes differed in the elderly patients above 80 years, Group A -13.3% vs Group C - 25%, although not statistically significant (p=0.23). There was a significant difference in mortality in patients of Group A - 40% as compared to 12% in the younger cohort, Group B (p= 0.01). Conclusions: In the extended time window, patients above 80 years of age were noted to have a higher mortality, morbidity compared to the younger cohort of patients. No significant differences were noted in the stroke outcomes in patients above 80 years of age when comparing the traditional and the extended time window for stroke treatment.

Intravenous Thrombolysis in Acute Ischemic Stroke

2018 ◽  
pp. 128-152
Author(s):  
Waldo R. Guerrero ◽  
Edgar A. Samaniego ◽  
Santiago Ortega
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
American Heart Association ◽  
American Heart ◽  
Time Window ◽  
Intravenous Thrombolysis ◽  
Heart Association ◽  
Standard Of Care

The only proven therapy for patients with acute ischemic stroke is early recanalization. The use of intravenous thrombolytic alteplase is the standard of care for patients presenting with ischemic stroke within the first 4.5 hours from symptom onset. This chapter reviews the indications and contraindications to alteplase including the 2015 American Heart Association guidelines and their relevance to clinical practice. Furthermore, emerging research and ongoing trials on expanding the time window for intravenous thrombolysis are discussed.

scholarly journals Endovascular Thrombectomy in Acute-Onset Ischemic Stroke – beyond the Standard Time Windows: A Case Report and a Review of the Literature

2018 ◽  
Vol 10 (3) ◽  
pp. 279-285 ◽  
Author(s):  
Conan  So ◽  
Naveed Chaudhry ◽  
Dheeraj Gandhi ◽  
John W. Cole ◽  
Melissa Motta
Keyword(s):  
Ischemic Stroke ◽  
Symptom Onset ◽  
Infarct Volume ◽  
Time Windows ◽  
Acute Onset ◽  
Cerebral Angiogram ◽  
Endovascular Thrombectomy ◽  
Completed Stroke ◽  
The Right ◽  
Current Guidelines

Endovascular thrombectomy following an acute ischemic stroke can lead to improved functional outcome when performed early. Current guidelines suggest treatment within 6 h after symptom onset. Recent studies including the DEFUSE-3 and DAWN trials demonstrate that some patients may benefit from thrombectomy up to 16 and 24 h after symptom onset, respectively. We present a case of delayed thrombectomy in a 43-year-old man with acute dysarthria, left-sided weakness, and visual neglect. Initial MRI/A demonstrated a small completed stroke and a thrombus in the right middle cerebral artery. Thirty-seven hours after symptom onset, his weakness acutely worsened. A repeat MRI revealed an unchanged core infarct volume and a cerebral angiogram suggested an abrupt occlusion of the right distal M1. Thrombectomy was performed with complete reperfusion and the patient’s strength recovered following the procedure. We compared our clinical reasoning with the DEFUSE-3 and DAWN study criteria, and conclude that there is a subset of patients that may safely benefit from thrombectomy in later time windows beyond the trial criteria, especially in the setting of clinical examination of imaging mismatch.

scholarly journals Predictor Naïve Temporal Baseline Hazard of Recurrent Ischemic Stroke

2022 ◽  
Author(s):  
Marwa Elsaeed Elhefnawy ◽  
Siti Maisharah Sheikh Ghadzi ◽  
Orwa Albitar ◽  
Balamurugan Tangiisuran ◽  
Hadzliana Zainal ◽  
...  
Keyword(s):  
Risk Factors ◽  
Ischemic Stroke ◽  
Significant Risk ◽  
Likelihood Estimation ◽  
Preventive Treatment ◽  
Hazard Models ◽  
Baseline Hazard ◽  
Time Points ◽  
History Of

Abstract There are established correlation between risk factors and the recurrence of ischemic stroke (IS), however does the hazard of recurrent IS change although without the influence of established risk factors? This study aimed to quantify the hazard of recurrent IS at different time points after the index IS. This was a population cohort study extracted data of 7697 patients with a history of first IS attack registered with National Neurology Registry of Malaysia. A repeated time to recurrent IS model was developed using NONMEM version 7.5. Three baseline hazard models were fitted into the data. The best model was selected using maximum likelihood estimation, clinical plausibility and visual predictive checks. Three hundred and thirty-three (4.32%) patients developed at least one recurrent IS within the maximum 7.37 years follow-up. In the absence of significant risk factors, the hazard of recurrent IS was predicted to be 0.71 within the first month after the index IS and reduced to 0.022 between the first to third months after the index attack. The hazard of IS recurrence accelerated with the presence of typical risk factors such as hyperlipidaemia (HR, 2.64 [2.10-3.33]), hypertension (HR, 1.97 [1.43-2.72], and ischemic heart disease (HR, 2.21 [1.69-2.87]). In conclusion, the absence of significant risk factors, predicted hazard of recurrent IS was prominent in the first month after the index IS and was non-zero even three months after the index IS or later. Optimal secondary preventive treatment should incorporate the ‘nature risk’ IS recurrence.

Abstract W P240: The Effect of Telestroke Network on Tissue Plasminogen Activator Utilization and Door to Needle Time on Rural Hospitals.

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Karina Castellon Larios ◽  
Katherine Rybka ◽  
Diana Greene-Chandos ◽  
Sergio Bergese ◽  
Michel Torbey
Keyword(s):  
Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Symptom Onset ◽  
Time Window ◽  
The United States ◽  
Rural Setting ◽  
Nihss Score ◽  
Number Of Patients ◽  
Tissue Plasminogen

Introduction: Stroke is the 4 th leading cause of death in the United States. Only 2-3% of ischemic stroke patients are receiving Tissue plasminogen activator (t-PA) despite an increase in time window to 4.5 hours. With less than 85% of the US population living within 30 minutes of primary stroke centers, it is important to review the effectiveness of telestroke network in delivering t-PA. The Ohio State University Wexner Medical Center (OSUWMC) Telestroke network was established in May 2011. Currently the network expands across 24 spokes located in rural central Ohio. Most of these centers have not given t-PA prior to joining the network. Objective: Evaluate the effectiveness of the OSUWMC telestroke in delivering t-PA for acute ischemic stroke in a rural setting and compare the stroke quality metrics to Ohio Coverdell registered Hospitals. Methods: We conducted a retrospective data review from the OSUWMC Telestroke Network database from May 22, 2011 to November 30, 2012. This included demographics, diagnostic impression, NIHSS score, average symptom onset to ED arrival, average door to CT time, average consult duration. t-PA administration and transfer status to OSUMWC were also collected. Summary statistics were generated using Microsoft Excel (version 2010, Microsoft Corporation) and SAS (version 9.3, SAS Institute). Results: In this study, a total of 422 Telestroke consultations were completed. 180 patients were diagnosed with ischemic stroke (57.5%). Average NIHSS score was 5 ±6, average symptom onset to ED arrival time was 4 hours 26 minutes (n=378), and the average door to CT time was 26 minutes (n=204). Forty-four percent (n=80) were approved to receive IV t-PA; 60% within one hour of ED arrival. From this number of patients thirty percent received t-PA within one hour compared to 38% in Ohio Coverdell hospitals. Conclusion: The implementation of telestroke network can deliver care that is equivalent to primary stroke centers. This approach may be an effective tool for rapid evaluation of patients in remote hospitals that require neurologic specialists.

Abstract TMP61: Acute Ischemic Stroke Emergency Department Arrival Times in the Extended Time Window Within a Population

Stroke ◽  
2018 ◽  
Vol 49 (Suppl_1) ◽  
Author(s):  
Dawn O Kleindorfer ◽  
Charles J Moomaw ◽  
Kathleen Alwell ◽  
Pooja Khatri ◽  
Daniel Woo ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Time Window ◽  
Extended Time ◽  
Arrival Times ◽  
Emergency Department Arrival

Cerebral blood volume Alberta Stroke Program Early Computed Tomography Score predicts intracranial hemorrhage after thrombectomy in patients with acute ischemic stroke in an extended time window

2021 ◽  
pp. 028418512199084
Author(s):  
Yue-Zhou Cao ◽  
Lin-Bo Zhao ◽  
Zhen-Yu Jia ◽  
Qiang-Hui Liu ◽  
Xiao-Quan Xu ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Blood Volume ◽  
Intracranial Hemorrhage ◽  
Cerebral Blood Volume ◽  
Time Window ◽  
Univariate Analysis ◽  
Lower Probability ◽  
Extended Time

Background Higher baseline Alberta Stroke Program Early Computed Tomography Score (ASPECTS) was associated with a lower probability of hemorrhagic transformation in patients with acute ischemic stroke (AIS). Purpose To investigate the predictive value of cerebral blood volume (CBV)-ASPECTS of intracranial hemorrhage (ICH) in AIS treated with thrombectomy selected by computed tomographic perfusion (CTP) in an extended time window. Material and Methods A total of 91 consecutive patients with AIS with large vessel occlusion in the anterior circulation after thrombectomy in an extended time window were enrolled between January 2018 and September 2019. ICH was diagnosed according to Heidelberg Bleeding Classification. CBV-ASPECTS was assessed by evaluating each ASPECTS region for relatively low CBV value compared with the mirror region in the contralateral hemisphere. Demographic characteristics, clinical data, CBV-ASPECTS, and procedure process and results were compared between patients with ICH and those without. Results ICH occurred in 31/91 (34.1%) patients with AIS. Symptomatic ICH (sICH) was observed in 4 (4.4%) patients, while asymptomatic ICH (aICH) was seen in 27 (29.7%). In univariate analysis, both ICH and aICH were associated with high admission NIHSS score ( P<0.001 and P<0.001, respectively), more passes of retriever ( P = 0.007 and P = 0.019, respectively), low NCCT-ASPECTS ( P = 0.013 and P = 0.034, respectively), and low CBV-ASPECTS ( P < 0.001 and P < 0.001, respectively). After multivariable analysis, low CBV-ASPECTS remained an independent predictor of ICH (odds ratio [OR] 0.521, 95% confidence interval [CI] 0.371–0.732, P < 0.001) and aICH (OR 0.532, 95% CI 0.376–0.752, P < 0.001), respectively. Conclusion Low CBV-ASPECTS independently predicts ICH in patients with AIS treated with thrombectomy selected by CTP in an extended time window.

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