Intraarterial Thrombolysis with r-tPA for Treatment of Anterior Circulation Acute Ischemic Stroke

To investigate factors effecting the safety and recanalization efficacy of local intraarterial (IA) recombinant tissue plasminogen activator (r-tPA) delivery in patients with acute ischemic stroke. Eleven patients with anterior circulation acute ischemic stroke were treated. The neurological status of the patients were graded with the Glasgow Coma Scale (GCS) and National Institute of Health Stroke Scale (NIHSS). All patients underwent a computed tomography (CT) examination at admission. In addition four patients had diffusion-weighted and one patient had a perfusion magnetic resonance (MR) examinations. Patients were treated within six hours from stroke onset. Immediate, six hours, and 24 hours follow-up CT examinations were performed in order to evaluate the haemorrhagic complications and the extent of the ischemic area. The Rankin Scale (RS) was used as an outcome measure. Two of the 11 patients had carotid “T” occlusion (CTO), nine had middle cerebral artery (MCA) main trunk occlusion. Four patients had symptomatic haemorrhage with a large haematoma rupturing into the ventricles and subarachnoid space. Of these, three patients died within 24 hours. The remaining seven patients had asymptomatic haematomas that were smaller compared to symptomatic ones, and showed regression in size and density on follow-up CTs. At third month five patients had a good outcome and three patients had a poor outcome. In acute ischemic stroke, local IA thrombolysis is a feasible treatment when you select the right patient. Haemorrhage rate does not seem to exceed that occuring in the natural history of the disease and in other treatment modalities.

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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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A Young Woman with Ischemic Stroke: Should We Pay More Attention to Varicella Zoster Infection

Case Reports in Neurology ◽

10.1159/000447296 ◽

2016 ◽

Vol 8 (2) ◽

pp. 145-150 ◽

Cited By ~ 5

Author(s):

Cláudia Borbinha ◽

João Pedro Marto ◽

Sofia Calado ◽

Miguel Viana-Baptista

Keyword(s):

Ischemic Stroke ◽

Hemorrhagic Transformation ◽

Vascular Events ◽

Varicella Zoster ◽

Fluid Analysis ◽

History Of ◽

The Right ◽

High Index Of Suspicion ◽

Varicella Zoster Infection

Ischemic and hemorrhagic stroke are recognized complications of Varicella zoster virus (VZV) infections, although uncommon and poorly documented. The authors report the case of a 31-year-old woman admitted with acute ischemic stroke of the right posterior cerebral artery and a history of a thoracic rash 1 month before. Aspirin and simvastatin were prescribed, but the patient suffered a stepwise deterioration the following days, with new areas of infarction on brain imaging. Despite no evidence of cardiac or large vessel embolic sources, anticoagulation was started empirically 6 days after stroke onset. One week later, symptomatic hemorrhagic transformation occurred. The diagnosis of VZV vasculopathy was then considered, and treatment with acyclovir and prednisolone was started with no further vascular events. Cerebrospinal fluid analysis and digital subtraction angiography findings corroborated the diagnosis. The patient was discharged to the rehabilitation center with a modified Rankin scale (mRS) score of 4. On the 6-month follow-up, she presented only a slight disability (mRS score 2). In conclusion, VZV vasculopathy needs to be considered in young adults with stroke. A high index of suspicion and early treatment seem to be important to minimize morbidity and mortality. Anticoagulation should probably be avoided in stroke associated with VZV vasculopathy.

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Intravenous fibrinolysis plus endovascular thrombectomy versus direct endovascular thrombectomy for anterior circulation acute ischemic stroke: clinical and infarct volume results.

10.21203/rs.2.482/v1 ◽

2019 ◽

Author(s):

Massimo Gamba ◽

Nicola Gilberti ◽

Enrico Premi ◽

Angelo Costa ◽

Michele Frigerio ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Safety Profile ◽

Infarct Volume ◽

Intravenous Thrombolysis ◽

Functional Independence ◽

Anterior Circulation ◽

Endovascular Thrombectomy ◽

Symptomatic Intracerebral Hemorrhage

Abstract Background and Purpose endovascular therapy (ET) is the standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). The role of adjunctive intravenous thrombolysis (IVT) in these patients is still unclear. The present study aims to test whether IVT plus ET (CoT, combined therapy) provides additional benefits over direct ET for anterior circulation AIS by LVO. Methods we performed a single center retrospective observational study of patients with AIS caused by anterior circulation LVO, referred to our center between January 2014 and January 2017 and treated with ET. The patients were divided in 2 groups based on the treatment they received: CoT and, if IVT contraindicated, direct ET. We compared functional recovery (modified Rankin at 3-months follow-up), recanalization rate (thrombolysis in cerebral infarction [TICI] score) and time, early follow-up infarct volume (EFIV) (for recanalized patients only) as well as safety profile, defined as symptomatic intracerebral hemorrhage (sICH) and 3-month mortality, between groups. Results 145 subjects were included in the study, 70 in direct ET group and 75 in CoT group. Patients who received CoT presented more frequently a functional independence at 3-months follow-up compared to patients who received direct ET (mRS score 0-1: 48.5% vs 18.6%; P<0.001. mRS score 0-2: 67.1% vs 37.3%; P<0.001), higher first-pass success rate (62.7% vs 38.6%, P<0.05), higher recanalization rate (84.3% vs 65.3%; P=0.009) and, in recanalized subjects, smaller EFIV (16.4ml vs 62.3ml; P=0.003). The safety profile was similar for the 2 groups. In multivariable regression analysis, low baseline NIHSS score (P<0.05), vessel recanalization (P=0.05) and CoT (P=0.03) were indipendent predictors of 3-month favorable outcome. Conclusions CoT appears more effective than ET alone for anterior circulation AIS with LVO, with similar safety profile.

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Factors Associated with Unsuccessful Recanalization in Mechanical Thrombectomy for Acute Ischemic Stroke

Cerebrovascular Diseases Extra ◽

10.1159/000503001 ◽

2019 ◽

Vol 9 (3) ◽

pp. 107-113 ◽

Cited By ~ 2

Author(s):

Toshiaki Goda ◽

Naoki Oyama ◽

Takaya Kitano ◽

Takanori Iwamoto ◽

Shinji Yamashita ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Univariate Analysis ◽

Single Center ◽

Patient Factors ◽

Anterior Circulation ◽

Factors Associated ◽

Female Sex ◽

History Of

Introduction: Mechanical thrombectomy (MT) for acute ischemic stroke has become a standard therapy, and the recanalization rate has significantly improved. However, some cases of unsuccessful recanalization still occur. We aimed to clarify patient factors associated with unsuccessful recanalization after MT for acute ischemic stroke. Methods: This was a single-center, retrospective study of 119 consecutive patients with anterior circulation acute ischemic stroke who underwent MT at our hospital between April 2015 and March 2019. Successful recanalization after MT was defined as modified Treatment in Cerebral Ischemia (mTICI) grade 2b or 3, and unsuccessful recanalization was defined as mTICI grades 0–2a. Several factors were analyzed to assess their effect on recanalization rates. Results: Successful recanalization was achieved in 88 patients (73.9%). The univariate analysis showed that female sex (38.6 vs. 67.7%, p = 0.007), a history of hypertension (53.4 vs. 83.9%, p = 0.003), and a longer time from groin puncture to recanalization (median 75 vs. 124 min, p < 0.001) were significantly associated with unsuccessful recanalization. The multivariate analysis confirmed that female sex (OR 3.18; 95% CI 1.12–9.02, p = 0.030), a history of hypertension (OR 4.84; 95% CI 1.32–17.8, p = 0.018), M2–3 occlusion (OR 4.26; 95% CI 1.36–13.3, p = 0.013), and the time from groin puncture to recanalization (per 10-min increase, OR 1.22; 95% CI 1.09–1.37, p < 0.001) were independently associated with unsuccessful recanalization. Conclusion: Female sex and a history of hypertension might be predictors of unsuccessful recanalization after MT for anterior circulation acute ischemic stroke. Further studies are needed to fully evaluate predictors of recanalization.

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Cohort study of THRIVE predicting adverse outcomes in acute ischemic stroke of the anterior circulation and posterior circulation after 3 months and 1 year of follow-up

Journal of Clinical Neuroscience ◽

10.1016/j.jocn.2021.12.004 ◽

2022 ◽

Vol 96 ◽

pp. 33-37

Author(s):

Li-Li Chen ◽

Shuang-mei Yan ◽

Wen-Ting Wang ◽

Sai Zhang ◽

Hui-Miao Liu ◽

...

Keyword(s):

Cohort Study ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Adverse Outcomes ◽

Posterior Circulation ◽

Anterior Circulation

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Abstract WMP15: A Simple Tool to Predict Target Mismatch in Ischemic Stroke Patients with Anterior Circulation Occlusion

Stroke ◽

10.1161/str.48.suppl_1.wmp15 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Adam de Havenon ◽

Steve O’Donnell ◽

Alex Linn ◽

Scott McNally ◽

Bailey Dunleavy ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Perfusion Imaging ◽

Time Window ◽

Ct Perfusion ◽

Volumetric Analysis ◽

Stroke Patients ◽

Anterior Circulation ◽

Ct Angiogram

Introduction: The efficacy of endovascular thrombectomy in an extended time window for acute ischemic stroke patients with Target Mismatch (TM) on perfusion imaging was shown in a recent study and the ongoing DEFUSE-3 trial is studying thrombectomy in a 6-16 hour window for TM patients. A limitation of TM is that perfusion imaging is not widely available. We sought to identify a tool to predict TM based on clinical factors and CT angiogram (CTA) imaging, which is available at most hospitals. Methods: We reviewed acute ischemic stroke patients from 2010-2014 with proximal middle cerebral artery occlusion, CTA and CT perfusion (CTP) at hospital admission. TM was identified on CTP using the Olea Sphere volumetric analysis software with Bayesian deconvolution. TM was defined by the DEFUSE-3 criteria. ASPECTS was derived from the non-contrast CT head and the CTA source images (CTA-ASPECTS). Two collateral scores were derived from CTA source images. Results: 61 patients met inclusion criteria. The mean±SD age was 61±18 years and 61% were male. Mean NIH Stroke Scale (NIHSS) was 14.1±8.0 and median (IQR) follow-up modified Rankin Scale was 3 (1,6). TM was present in 35/61 (57%), who had lower mRS at follow-up (z=3.5, p<0.001). The predictor variables are shown in Table 1. The best combination of predictors was CTA-ASPECTS >4 and NIHSS <16, which had a sensitivity of 80% and specificity of 85% for TM (Figure 1). Discussion: We report a reliable, accessible, and clinically useful tool for predicting TM. This score warrants further study as a tool to guide transfer decisions from primary or secondary stroke centers to tertiary centers where endovascular intervention would be possible for selected patients.

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Abstract W P17: Factors Associated With DWI Lesion Growth After Endovascular Therapy for Acute Ischemic Stroke

Stroke ◽

10.1161/str.45.suppl_1.wp17 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Shumei Man ◽

M. Shazam Hussain ◽

Dolora Wisco ◽

Esteban Cheng-ching ◽

Toshiya Osanai ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Infarct Volume ◽

Cleveland Clinic ◽

Antiplatelet Agents ◽

Lesion Size ◽

Anterior Circulation ◽

Ischemic Lesion ◽

Large Growth

Background: The factors impacting infarct evolution after intra-arterial(IA) intervention for acute ischemic stroke remain uncertain. We studied the infarct evolution on MRI DWI among acute stroke patients who underwent IA therapy. Methods: We reviewed the early ischemic stroke imaging database at Cleveland Clinic Cerebrovascular Center for those undergoing IA therapy in anterior circulation from 2009 to 2012. Patients with both pre-treatment and follow-up MRI were included. Infarct volume was measured on initial and follow-up DWI by region of interest demarcation. Patients were grouped into quartiles by infarct growth from initial to follow-up. Outcome were defined as modified Rankin Score 0-2 at 30 days. Results: Among the 76 patients, the median (range) infarct growth of four quartiles were 0.5 cc (-19.1-4.2), 13.8 cc (4.8-25.8), 38.8 cc (28.0-77.6), and 166.3 cc (78.0-314.5). Baseline characteristics of age, gender, race, diabetes, and hypertension were similar among groups except more smokers (p=0.017) and fewer patients on anticoagulation or antiplatelet agents in large-growth group (p=0.049). Compared to No-growth group (Quartile 1), large-growth group (Quartile 4) had more Hyperdense M1 MCA sign ( 26.3% vs 73.7%, p=0.004), larger initial ischemic lesion measured by CT ASPECT (p=0.002) and DWI volume (p=0.012), and absence of full collaterals on CTA ( 36.8% vs 0, p=0.004). There was a trend of lower recanalization rate in large-growth group (73.7% vs 47.4%, p=0.097). With the increment of infarct growth, there is a decrement in favorable outcomes (mRS 0-2) at 30 days: 42%, 37%, 26% and 10.5% (p=0.027). Conclusion: Infarct growth after IA therapy determines outcome. Initial ischemic lesion size, collaterals, and hyperdense vessel sign are associated with infarct growth.

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Abstract WMP13: Multiphase MRA Collateral Map: Prediction of Tissue Outcome and Penumbra in Patients With Acute Ischemic Stroke in the Anterior Circulation

Stroke ◽

10.1161/str.51.suppl_1.wmp13 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Hyun Jeong KIM ◽

Taek Jun Lee ◽

Hong Gee Roh ◽

Jeong Jin Park ◽

Hyung Jin Lee ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcomes ◽

Mr Angiography ◽

Visual Assessment ◽

Anterior Circulation ◽

Early Reperfusion ◽

Infarct Area ◽

Dynamic Mr

Background and Purpose: We developed the MRA collateral map derived from dynamic MR angiography and grading methods with significant linear association with functional outcomes of patients with acute ischemic stroke (AIS). This study is to verify the value of the MRA collateral map for predicting tissue outcome and penumbra in patients with AIS. Materials and Methods: From a prospectively maintained registry, patients with AIS due to occlusion or stenosis of the unilateral ICA and/or M1 MCA within 8 hours of symptom onset were included. The collateral-perfusion grading based on the MRA collateral map was estimated using 6-scale MAC. Changes of infarct area were divided into two groups with and without infarct growth (IG + and IG - ). Areas of baseline DWI lesion, Tmax > 6s, and decreased collateral-perfusion on each phases of the MRA collateral map, and infarct lesion on follow-up image were compared by visual assessment. Results: One hundred thirty-five patients, including 85 males (mean age, 69 years old), were included. Shorter onset-to-door times (OR=1.04, 95% CI=1.01-1.08) and successful early reperfusion (OR=0.19, 95% CI=0.05-0.66) were independently associated with IG - in multivariate analysis. In subgroup analysis, good collateral-perfusion status was associated with IG - (OR=0.30, 95% CI=0.10-0.91). In IG + group, the infarction grew within hypoperfused area on the phase of the MRA collateral map immediately before the phase that matches the baseline DWI lesion. There was no infarct growth beyond hypoperfused area on the capillary phase of the MRA collateral map in both IG + and IG - groups. The area of Tmax > 6s matched with the hypoperfused area on capillary phase of the MRA collateral map in 83% of patients. Conclusion: In this study, tissue fate in AIS was dependent on early reperfusion. In case of unsuccessful early reperfusion, it was associated with collateral-perfusion status. We suggest that the extent of penumbra can be estimated by the MRA collateral map.

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PREDICTORS THE RISK OF SYMPTOMATIC INTRACEREBRAL HEAMORHAGE AFTER THROMBOLYTIC THERAPY WITH RECOMBINANT TISSUE PLASMINOGEN ACTIVATOR IN ACUTE ISCHEMIC STROKE

Journal of Medicine and Pharmacy ◽

10.34071/jmp.2017.2.11 ◽

2017 ◽

pp. 64-67

Author(s):

Dinh Thuyen Nguyen ◽

Duy Ton Mai ◽

Viet Phuong Dao ◽

Anh Tuan Nguyen

Keyword(s):

Ischemic Stroke ◽

Thrombolytic Therapy ◽

Acute Ischemic Stroke ◽

Plasminogen Activator ◽

Tissue Plasminogen Activator ◽

Recombinant Tissue Plasminogen Activator ◽

Brain Ct ◽

Tissue Plasminogen ◽

History Of ◽

Stroke Thrombolysis

Objective: to evaluate predictors the risk of symptomatic intracerebral heamorrhage after thrombolytic therapy with recombinant tissue plasminogen activator in acute ischemic stroke. Methods: observative study on 54 patients with acute ischemic stroke at Emergency Department, Bach Mai hospital from 01/2010 to 10/2016. Results: Predictors the risk of symptomatic intracerebral heamorrhage were: age above 70 (OR 2,76; 95% CI 0,73 – 10,52; p = 0,12), time from onset to treatment (OR 1,03; 95% CI 0,34 – 3,13; p = 0,95), systolic blood pressure ≥ 140 mmHg (OR 2,0; 95% CI 0,61 – 6,51; p = 0,24), NIHSS score above 12 (OR 3,13; 95% CI 0,63 – 15,51; p = 0,138), glycemia above 10 mmol/l (OR 8,94; 95% CI 1,51 – 51,73; p = 0,003), fibrillation atrial (OR 1,49; 95% 0,49 – 4,56; p = 0,33), history of diebete (OR 6,4; 95% CI 0,67 – 61,03; p = 0,06), history of anticoagulation (OR 1,07; 95% CI 0,22 – 5,11; p = 0,63), history of cerebral infarction (OR 1,49; 95% CI 0,183 – 12,184; p = 0,707), sign of early brain CT (OR 6,14; 95% CI 1,01 – 39,93; p = 0,048). Conclusion: glucose above 10 mmol/l and sign of early brain CT were predictors the risk of symptomatic intracerebral heamorrhage after thrombolytic therapy with recombinant tissue plasminogen activator in acute ischemic stroke. Key words: stroke, thrombolysis, predictor, heamorrhage conversion

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Association of follow-up infarct volume with functional outcome in acute ischemic stroke: a pooled analysis of seven randomized trials

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013724 ◽

2018 ◽

Vol 10 (12) ◽

pp. 1137-1142 ◽

Cited By ~ 26

Author(s):

Anna M M Boers ◽

Ivo G H Jansen ◽

Ludo F M Beenen ◽

Thomas G Devlin ◽

Luis San Roman ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Imaging Modality ◽

Infarct Volume ◽

Pooled Analysis ◽

Acquisition Time ◽

Anterior Circulation ◽

Multivariable Regression Models

BackgroundFollow-up infarct volume (FIV) has been recommended as an early indicator of treatment efficacy in patients with acute ischemic stroke. Questions remain about the optimal imaging approach for FIV measurement.ObjectiveTo examine the association of FIV with 90-day modified Rankin Scale (mRS) score and investigate its dependency on acquisition time and modality.MethodsData of seven trials were pooled. FIV was assessed on follow-up (12 hours to 2 weeks) CT or MRI. Infarct location was defined as laterality and involvement of the Alberta Stroke Program Early CT Score regions. Relative quality and strength of multivariable regression models of the association between FIV and functional outcome were assessed. Dependency of imaging modality and acquisition time (≤48 hours vs >48 hours) was evaluated.ResultsOf 1665 included patients, 83% were imaged with CT. Median FIV was 41 mL (IQR 14–120). A large FIV was associated with worse functional outcome (OR=0.88(95% CI 0.87 to 0.89) per 10 mL) in adjusted analysis. A model including FIV, location, and hemorrhage type best predicted mRS score. FIV of ≥133 mL was highly specific for unfavorable outcome. FIV was equally strongly associated with mRS score for assessment on CT and MRI, even though large differences in volume were present (48 mL (IQR 15–131) vs 22 mL (IQR 8–71), respectively). Associations of both early and late FIV assessments with outcome were similar in strength (ρ=0.60(95% CI 0.56 to 0.64) and ρ=0.55(95% CI 0.50 to 0.60), respectively).ConclusionsIn patients with an acute ischemic stroke due to a proximal intracranial occlusion of the anterior circulation, FIV is a strong independent predictor of functional outcome and can be assessed before 48 hours, oneither CT or MRI.

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