Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.

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Meta-analysis of the Smoker’s Paradox in Acute Ischemic Stroke Patients Receiving Intravenous Thrombolysis or Endovascular Treatment

Nicotine & Tobacco Research ◽

10.1093/ntr/ntz094 ◽

2019 ◽

Vol 21 (9) ◽

pp. 1181-1188 ◽

Cited By ~ 1

Author(s):

Peng Zhang ◽

Zhen-Ni Guo ◽

Xin Sun ◽

Yingkai Zhao ◽

Yi Yang

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Functional Outcomes ◽

Meta Analysis ◽

Intravenous Thrombolysis ◽

Cochrane Library ◽

Stroke Patients ◽

Good Functional Outcome

Abstract Introduction The existence of the smoker’s paradox is controversial and potential mechanisms have not been explained. We aimed to explore the association between cigarette smoking and functional outcome at 3 months in patients with acute ischemic stroke who were treated with intravenous thrombolysis (IVT) or endovascular treatment (EVT). Methods This meta-analysis was conducted in accordance with the PRISMA guidelines. Studies exploring the association between smoking and good functional outcome (modified Rankin Scale score ≤ 2) following IVT or EVT were searched via the databases of PubMed, Embase, and the Cochrane Library from inception to August 8, 2018. Information on the characteristics of included studies was independently extracted by two investigators. Data were pooled using a random-effects or fixed-effects meta-analysis according to the heterogeneity of included studies. Results Among 20 identified studies, 15 reported functional outcomes following IVT, and five reported functional outcomes following EVT. Unadjusted analyses showed that smoking increased the odds of good functional outcomes with a pooled odds ratio (OR) of 1.48 (95% confidence interval [CI]: 1.36–1.60) after IVT and 2.10 (95% CI: 1.47–3.20) after EVT. Of IVT studies, only eight reported outcomes adjusted for covariates and none of the EVT studies reported adjusted outcomes. After adjustment, the relation between smoking and good functional outcome following IVT lost statistical significance (OR 1.14 [95% CI: 0.81–1.59]). Conclusion Our meta-analysis suggested that smoking was not associated with good functional outcome (mRS ≤ 2) at 3 months in patients with acute ischemic stroke who were treated with intravenous thrombolysis. Implications The existence of the smoker’s paradox is controversial. A previous letter by Plas et al. published in 2013 reported a positive result for the association between smoking and good functional outcome at 3 months in acute ischemic stroke patients who received intravenous thrombolysis (IVT). However, a major limitation of their meta-analysis was that the process of data synthesis was based on unadjusted data. Therefore, we conducted this meta-analysis to investigate the association based on adjusted data and a larger sample size. Our meta-analysis suggested that smoking was not associated with good functional outcome after adjusting for covariates.

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Abstract TP56: Endovascular Treatment Decisions in Acute Ischemic Stroke Patients With Low Baseline Aspects: Insights From an International Multidisciplinary Survey

Stroke ◽

10.1161/str.51.suppl_1.tp56 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Johanna M Ospel ◽

Nima Kashani ◽

Bijoy Menon ◽

Mohammed Almekhlafi ◽

Ravinder Singh ◽

...

Keyword(s):

Decision Making ◽

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Multivariable Logistic Regression Analysis ◽

Stroke Patients ◽

Acute Stroke Care ◽

Early Management ◽

Local Resources

Background and Purpose: Current AHA/ASA guidelines for the early management of patients with acute ischemic stroke restrict level 1A recommendations for endovascular therapy (EVT) to patients with baseline ASPECTS score >5. However, a recent meta-analysis from the HERMES group showed a treatment benefit in patients with ASPECTS ≤5. We aimed to explore how physicians across different specialties and countries approach endovascular treatment decision-making in acute ischemic stroke patients with low baseline ASPECTS. Methods: In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 out of a pool of 22 case-scenarios, 3 of which involved patients with baseline ASPECTS < 6 (A: 40-year old with ASPECTS 4, B: 33-year old with ASPECTS 2 C: 72-year old with ASPECTS 3), otherwise fulfilling all EVT-eligibility criteria. Participants were asked how they would treat the patient in the given scenario A) under their current local resources and B) under assumed ideal conditions, i.e. without any external (monetary, policy-related or infrastructural) restraints. Overall and scenario-specific decision rates were calculated. Clustered multivariable logistic regression analysis was used to determine variables associated with EVT decision in patients with low baseline ASPECTS. Results: 827/6070 responses were available for the low ASPECTS scenarios. Current and ideal treatment EVT decision rates were 57.1% and 57.6% respectively. Current and ideal decision rates were 69.9% and 60.4% for scenario A, 60.0% and 61.5% for scenario B, 41.3% and 40.2% for scenario C respectively. Annual center EVT volume (OR 1.004,p=.004), annual operator EVT volume (OR 1.009, p=.018) and time since symptom onset (OR 4.543,p<.001) were significantly associated with EVT decision-making under current local resources, while annual operator EVT volume (OR 1.007,p<.029) and time since symptom onset (OR 5.687,p<.001) were associated with decision-making under assumed ideal conditions. Conclusion: A majority of physicians decided to proceed with EVT despite low baseline ASPECTS. Operators and centers doing more EVT per year were more likely to offer EVT to patients with low ASPECTS.

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A Comparison of Endovascular Treatment with Intravenous Thrombolysis in Acute Ischemic Stroke Patients with Mild Deficits (P06.216)

Neurology ◽

10.1212/wnl.78.1_meetingabstracts.p06.216 ◽

2012 ◽

Vol 78 (Meeting Abstracts 1) ◽

pp. P06.216-P06.216

Author(s):

N. Rostambeigi ◽

A. Hassan ◽

S. Chaudhry ◽

H. Zacharatos ◽

W. Tekle ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Stroke Patients

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Abstract W P8: "Double Trouble": Endovascular Treatment of Tandem Arterial Occlusions in Acute Ischemic Stroke

Stroke ◽

10.1161/str.46.suppl_1.wp8 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Mikayel Grigoryan ◽

Diogo Haussen ◽

Andrey Lima ◽

Jonathan Grossberg ◽

Shannon Doppelheuer ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Arterial Occlusion ◽

Intravenous Thrombolysis ◽

Imaging Data ◽

Stroke Patients ◽

Symptomatic Intracerebral Hemorrhage

Background: Tandem extracranial/intracranial arterial occlusions in acute stroke present treatment challenges both due to suboptimal response to systemic intravenous thrombolysis as well as complex endovascular approach. We report our experience in treating this cohort of acute stroke patients with the analysis of angiographic and clinical outcomes Materials and Methods: We retrospectively reviewed clinical and imaging data of all consecutive acute stroke patients with proximal intracranial arterial occlusion and additional extracranial occlusion/critical stenosis, treated with endovascular techniques between February 2011 and February 2014 at two hospitals. We analyzed patients’ demographics, clinical presentation, treatment strategies, time to recanalization, imaging and clinical outcomes. Results: A total of 66 patients were included. The mean NIHSS on presentation was 19. Extracranial carotid with concomitant intracranial anterior circulation occlusions were present in 95% of the patients (63/66), while 5% (3/66) had tandem vertebrobasilar occlusions. 41% of the patients (27/66) received intravenous rt-PA. With regards to endovascular treatment, in 70% of the cases (46/66), extracranial lesion was treated with a stent placement. Stentrievers were used in 50% (33/66) of the patients for intracranial thrombectomy. Thrombolysis in Cerebral Infarction (TICI) >= 2B reperfusion was achieved in 77% of all the patients (51/66) and in 97% (32/33) of the stentriever patients. Good clinical outcome at 90 days (mRS<=2) was seen in 42% of the patients. Symptomatic intracerebral hemorrhage (PH-2)occurred in 9% (6/66) of the patients. Conclusions: Endovascular treatment of tandem arterial occlusions in acute ischemic stroke is relatively safe, feasible, and may yield excellent angiographic and good clinical outcomes.

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Abstract WP73: Comparison of Clinical Scores for Symptomatic Intracerebral Hemorrhage After Intravenous Thrombolysis

Stroke ◽

10.1161/str.48.suppl_1.wp73 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Kazunari Homma ◽

Shunya Takizawa ◽

Youichi Ohnuki

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Good Accuracy ◽

Intravenous Thrombolysis ◽

Predictive Performance ◽

Predictive Score ◽

Stroke Patients ◽

Symptomatic Intracerebral Hemorrhage ◽

Ct And Mri

Background: Stroke guidelines recommend that thrombolytic therapy should be carried out within 60 minutes from the arrival at the hospital. CT may decrease door-to-treatment interval compared to MRI. However, MRI may provide more information on brain pathology to select the treatment than CT. Thus, it remains controversial which is informative for selecting thrombolysis and endovascular treatment in acute ischemic stroke between CT and MRI. Purpose: Purpose of this study is to evaluate which clinical risk score using CT or MRI presents the best predictive performance for symptomatic intracranial hemorrhage (SICH). Methods: Consecutive stroke patients suffering anterior circulation were analyzed, who were received IV rt-PA therapy between October 2005 and March 2016. We calculated nine scores for each patient: DRAGON, MRI-DRAGON, HAT, SEDAN, SITS-ICH, SPAN-100, ASTRAL, PRS, and GRASPS. The area under the receiver operating characteristic curve was calculated to determine the predictive performance of each SICH predictive score according to two criteria: NINDS and ECASS-II. Logistic regression determined the odds ratio for two SICH criteria. Results: A total of 166 acute ischemic stroke patients were analyzed (113 men, 72±12 years old). SICH defined following NINDS criteria occurred in 14 patients, SICH defined following ECASS criteria occurred in 11 patients. 144 patients were performed both CT and MRI [median time between CT and MRI, 11; IQR 8-16]. Only 2 scores predicted SICH (NINDS criteria) with good accuracy (ROC area> 0.7, Figure1). Only one score predicted SICH (NINDS criteria) with good accuracy (Figure2). Conclusion: We concluded that MRI-DRAGON presented the best predictive performance for SICH, and MRI may be more useful for selecting thrombolysis and endovascular treatment in acute ischemic stroke than CT.

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Abstract TP2: Disparities in Delivery of Endovascular Therapy: Who Gets it and Where? The Florida Puerto Rico Collaboration to Reduce Stroke Disparities Study

Stroke ◽

10.1161/str.48.suppl_1.tp2 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Negar Asdaghi ◽

Lais Granzoti Cintra ◽

Kefeng Wang ◽

Maria A Ciliberti-Vargas ◽

Sebastian Koch ◽

...

Keyword(s):

Puerto Rico ◽

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Multivariable Analysis ◽

Intravenous Thrombolysis ◽

South Florida ◽

Stroke Patients ◽

Endovascular Thrombectomy

Background and Purpose: Endovascular thrombectomy improves functional outcome in select ischemic stroke patients. In the NINDS-funded CReSD Registry we sought to determine the clinical, hospital and regional characteristics associated with use of this therapy in patients presenting with acute ischemic stroke. Methods: Ischemic stroke patients within 24 hours of onset were prospectively included from 82 sites in Florida and Puerto Rico from January 2010 to April 2016. Independent predictors of endovascular therapy were evaluated using multivariable logistic regression with generalized estimating equations. Results: Among 58,204 patients with acute ischemic stroke (50% male, 65% white, 15% black, 20% Hispanic, mean age±SD 71±14 yrs), 2105 (3.6%) received endovascular thrombectomy (50.9% men, 62.3% white, 13.7% black, 24% Hispanic, mean age±SD 70±15yrs) with (35.2%) or without intravenous thrombolysis. Patients who received endovascular therapy had a significantly lower risk of vascular risk factors except for Afib (33.7% vs 19.0%), more severe strokes (median NIHSS 15 vs. 5) and were more likely to arrive quickly (126 min vs. 210 min), via EMS (70.4% vs. 59.6%) or as a transfer from another hospital (20.8% vs 5.8%,) during working hours (47.7% vs. 45.6%), to large hospitals (≥ 680 beds) (48.3% vs 28.8%), and treated in South Florida (47.3% vs. 35.9%) as compared to those not receiving this treatment. In multivariable analysis; age (OR 0.97, 95% CI 0.96- 0.98), Blacks (OR 0.68, 95% CI 0.56-2.28) vs. White, off-hour presentation (OR 0.76, 95% CI 0.66- 0.96), to regions other than South Florida (North OR 0.40, 95% CI 0.17-0.93, Panhandle OR 0.12, 95% CI 0.04-0.36) remained independently associated with lower use of endovascular therapy. In contrast, Hispanics (OR 1.28, 95% CI 1.03- 1.69) vs. White and presenting to large hospital (OR 4.92, 95% CI 1.05- to 22.6) were associated with higher use of endovascular treatment. Conclusions: There are significant race, regional and hospital disparities in delivery of endovascular care. Efforts should me made to improve access to endovascular treatment in patients presenting across the region to all stroke centers.

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Abstract TP15: Long-term Magnetic Resonance Angiography Follow-up of Recanalized Vessels After Mechanical Clot Extraction

Stroke ◽

10.1161/str.44.suppl_1.atp15 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Yukiko Enomoto ◽

Shinichi Yoshimura ◽

Yusuke Egashira ◽

Toru Iwama

Keyword(s):

Ischemic Stroke ◽

Magnetic Resonance ◽

Magnetic Resonance Angiography ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Stroke Patients ◽

Extraction Device

Objectives: Endovascular treatment provides a therapeutic option for acute ischemic stroke patients who are ineligible for, or who do not respond to intravenous thrombolysis. Higher rates of recanalization by mechanical clot extraction device were reportedly associated with better clinical outcome, but the long-term patency of recanalized vessel is unknown. Methods: We retrospectively evaluated magnetic resonance angiography (MRA) at 24-hour and 3-month after the endovascular treatment in consecutive acute stroke patients who were treated with mechanical clot extraction device between Oct. 2010 and May 2012 in our institution. Results: Fourty-six patients received endovascular treatment for acute ischemic stroke and 35 were treated with mechanical clot extraction devices, Merci and/or Penumbra system, with or without adjunctive therapy. Mean age was 69±12 years, baseline median National Institutes of Health Stroke Scale score was 15 (8 to 24), and occluded vessels were the internal carotid artery in 34%, middle cerebral artery (MCA) in 54%, and vertebro-basilar artery in 11%. Successful recanalization, defined as Thrombolysis In Myocardial Infarction II or III perfusion, was obtained in 32 (91%) patients. During 24-hour after the treatment, reocclusion of the treated vessel was observed in 4 (12.5%) patients. Of 28 eligible patients, 21 (75%) patients had 3-month MRA follow-up. None of the patients had reocclusion, but clinically silent diffuse stenosis was observed in 2 (9.5%) patients. Statistically significant predictors were not identified, but both of the patients were MCA occlusion treated with Merci retriever. Conclusion: In this study, late stenosis was observed in the MCA on 3-month follow-up MRA. Long-term follow-up seems to be useful to follow the recanalized vessels, especialy when mechanical devices were used.

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Management of acute ischemic stroke in patients with COVID-19 infection: Report of an international panel

International Journal of Stroke ◽

10.1177/1747493020923234 ◽

2020 ◽

Vol 15 (5) ◽

pp. 540-554 ◽

Cited By ~ 39

Author(s):

Adnan I Qureshi ◽

Foad Abd-Allah ◽

Fahmi Al-Senani ◽

Emrah Aytac ◽

Afshin Borhani-Haghighi ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Current Knowledge ◽

Intravenous Thrombolysis ◽

Adult Patients ◽

World Health ◽

Stroke Patients ◽

International Panel ◽

Health Organization ◽

Tract Infections

Background and purpose On 11 March 2020, World Health Organization (WHO) declared the COVID-19 infection a pandemic. The risk of ischemic stroke may be higher in patients with COVID-19 infection similar to those with other respiratory tract infections. We present a comprehensive set of practice implications in a single document for clinicians caring for adult patients with acute ischemic stroke with confirmed or suspected COVID-19 infection. Methods The practice implications were prepared after review of data to reach the consensus among stroke experts from 18 countries. The writers used systematic literature reviews, reference to previously published stroke guidelines, personal files, and expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulate practice implications. All members of the writing group had opportunities to comment in writing on the practice implications and approved the final version of this document. Results This document with consensus is divided into 18 sections. A total of 41 conclusions and practice implications have been developed. The document includes practice implications for evaluation of stroke patients with caution for stroke team members to avoid COVID-19 exposure, during clinical evaluation and performance of imaging and laboratory procedures with special considerations of intravenous thrombolysis and mechanical thrombectomy in stroke patients with suspected or confirmed COVID-19 infection. Conclusions These practice implications with consensus based on the currently available evidence aim to guide clinicians caring for adult patients with acute ischemic stroke who are suspected of, or confirmed, with COVID-19 infection. Under certain circumstances, however, only limited evidence is available to support these practice implications, suggesting an urgent need for establishing procedures for the management of stroke patients with suspected or confirmed COVID-19 infection.

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Incorporation of α2-Plasmin Inhibitor into Fibrin Clots and Its Association with the Clinical Outcome of Acute Ischemic Stroke Patients

Biomolecules ◽

10.3390/biom11030347 ◽

2021 ◽

Vol 11 (3) ◽

pp. 347

Author(s):

Zsuzsa Bagoly ◽

Barbara Baráth ◽

Rita Orbán-Kálmándi ◽

István Szegedi ◽

Réka Bogáti ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intracranial Hemorrhage ◽

Intravenous Thrombolysis ◽

Fibrin Clot ◽

Clot Lysis ◽

Stroke Patients ◽

Plasmin Inhibitor ◽

Fibrin Clots

Cross-linking of α2-plasmin inhibitor (α2-PI) to fibrin by activated factor XIII (FXIIIa) is essential for the inhibition of fibrinolysis. Little is known about the factors modifying α2-PI incorporation into the fibrin clot and whether the extent of incorporation has clinical consequences. Herein we calculated the extent of α2-PI incorporation by measuring α2-PI antigen levels from plasma and serum obtained after clotting the plasma by thrombin and Ca2+. The modifying effect of FXIII was studied by spiking of FXIII-A-deficient plasma with purified plasma FXIII. Fibrinogen, FXIII, α2-PI incorporation, in vitro clot-lysis, soluble fibroblast activation protein and α2-PI p.Arg6Trp polymorphism were measured from samples of 57 acute ischemic stroke patients obtained before thrombolysis and of 26 healthy controls. Increasing FXIII levels even at levels above the upper limit of normal increased α2-PI incorporation into the fibrin clot. α2-PI incorporation of controls and patients with good outcomes did not differ significantly (49.4 ± 4.6% vs. 47.4 ± 6.7%, p = 1.000), however it was significantly lower in patients suffering post-lysis intracranial hemorrhage (37.3 ± 14.0%, p = 0.004). In conclusion, increased FXIII levels resulted in elevated incorporation of α2-PI into fibrin clots. In stroke patients undergoing intravenous thrombolysis treatment, α2-PI incorporation shows an association with the outcome of therapy, particularly with thrombolysis-associated intracranial hemorrhage.

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Outcome of endovascular treatment within and beyond 6 h without perfusion software

Scientific Reports ◽

10.1038/s41598-021-84857-8 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Zhen Jing ◽

Hao Li ◽

Shengming Huang ◽

Min Guan ◽

Yongxin Li ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

General Anesthesia ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Symptom Onset ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Group A ◽

Group B

AbstractEndovascular treatment (EVT) has been accepted as the standard of care for patients with acute ischemic stroke. The aim of the present study was to compare clinical outcomes of patients who received EVT within and beyond 6 h from symptom onset to groin puncture without perfusion software in Guangdong district, China. Between March 2017 and May 2018, acute ischemic stroke patients who received EVT from 6 comprehensive stroke centers, were enrolled into the registry study. In this subgroup study, we included all patients who had acute proximal large vessel occlusion in the anterior circulation. The demographic, clinical and neuroimaging data were collected from each center. A total of 192 patients were included in this subgroup study. They were divided into two groups: group A (n = 125), within 6 h; group B (n = 67), 6–24 h from symptom onset to groin puncture. There were no substantial differences between these two groups in terms of 90 days favorable outcome (modified Rankin scale [mRS] ≤ 2, P = 0.051) and mortality (P = 0.083), and the risk of symptomatic intracranial hemorrhage at 24 h (P = 0.425). The NIHSS (median 16, IQR12-20, group A; median 12, IQR8-18, group B; P = 0.009) and ASPECTS (median 10, IQR8-10, group A; median 9, IQR8-10, group B; P = 0.034) at baseline were higher in group A. The anesthesia method (general anesthesia, 21.3%, group A vs. 1.5% group B, P = 0.001) were also statistically different between the two groups. The NIHSS and ASPECTS were higher, and general anesthesia was also more widely used in group A. Clinical outcomes were not significantly different within 6 h versus 6–24 h from symptom onset to groin puncture in this real world study.

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