Editorial: Intracranial Bleeding After Reperfusion Therapy in Acute Ischemic Stroke

BackgroundAnticoagulated patients (APs) are currently excluded from acute ischemic stroke reperfusion therapy with intravenous recombinant tissue plasminogen activator (IV-rtPA); however, these patients could benefit from mechanical thrombectomy (MT). Evidence for MT in this condition remains scarce. The aim of this study was to analyze the safety and efficacy of MT in APs.MethodsWe analyzed three patient groups from two prospective registries: APs with MT (AP-MT group), non-anticoagulated patients treated with MT (NAP-MT group), and non-anticoagulated patients treated with IV-rtPA and MT (NAP-IVTMT group). Univariate and multivariate logistic regression were used to evaluate treatment efficacy with modified Rankin Scale (mRS) ≤2 and safety (radiologic intracranial hemorrhage (rICH), symptomatic intracranial hemorrhage (sICH) and death rate at 3 months) between groups.Results333 patients were included in the study, with 44 (12%) in the AP-MT group, 105 (31%) in the NAP-MT group, and 188 (57%) in the NAP-IVTMT group. Univariate analysis showed that the AP-MT group was older (P<0.001), more often had atrial fibrillation (P<0001), and had a higher ASPECTS (P<0.006 and P<0.002) compared with the NAP-MT group and NAP-IVTMT groups, respectively. Multivariate analysis showed that the AP-MT group had a lower risk of rICH (OR 2.77, 95% CI 1.01 to 7.61, P=0.05) but a higher risk of death at 3 months (OR 0.26, 95% CI 0.09 to 0.76, P=0.01) compared with the NAP-IVTMT group. No difference was found between the AP-MT and NAP-MT groups.ConclusionsWith regard to intracranial bleeding and functional outcome at 3 months, MT in APs seems as safe and efficient as in NAPs. However, there is a higher risk of death at 3 months in the AP-MT group compared with the NAP-IVTMT group.

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Abstract WP22: Reperfusion Therapy After Neurological Deterioration in Acute Ischemic Stroke

Stroke ◽

10.1161/str.51.suppl_1.wp22 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Mooseok Park ◽

Tai Hwan Park ◽

Sang-Soon Park ◽

Jong-Moo Park ◽

Yong-Jin Cho ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Features ◽

Statistical Significance ◽

Multivariable Analysis ◽

Reperfusion Therapy ◽

Neurological Deterioration ◽

Large Artery ◽

Good Outcome ◽

Intravenous Tissue Plasminogen Activator

Background: Guidelines do not recommend reperfusion therapy in acute ischemic stroke patients with mild symptoms considering low gain compared to the risk. However, some patients with mild first symptoms experience neurological deterioration (ND) after hospitalization. We aimed to analyze clinical features and outcomes of patient who received reperfusion therapy after ND occurred. Methods: We enrolled patients who were admitted within 7 days after acute ischemic stroke or TIA between January 2012 and July 2018 from a multicenter stroke registry database in Korea (CRCS-K). Patients who 1) admitted via emergency room, and 2) received reperfusion therapy including intravenous tissue plasminogen activator and/or endovascular treatment were included. Clinical features and outcomes such as modified Rankin Scale (mRS) score distribution at 3 months after stroke were compared between patients received reperfusion therapy after ND and those without ND before the treatment. Results: Among 51325 patients, 6577 (12.8%) received reperfusion therapy were identified. Reperfusion therapy was performed after ND in 136 patients (2.1%). Mean time of onset to needle is 342.1 and 167.2, and onset to perfusion is 1351.6 and 422.0 in patients treated after ND, and those without, respectively. TIA history was more frequent and atrial fibrillation history was less frequent in patients treated after ND. Initial median (IQR) National Institute of Health Stroke Scale (NIHSS) score was 8 (5 - 12), 10 (6 - 16) in patients treated after ND, and those without, respectively. Large artery atherosclerosis was more frequent in patients treated after ND (42.9 % vs. 26.7%). There was higher rate of good outcome at 90 days in patients treated after ND (84 [61.8%]) compared with those without ND before treatment (3359 [52.2%]; OR, 1.38 [95% CI, 1.02-1.87]). In multivariable analysis, good outcome at 90 days in patients treated after ND lacked statistical significance (OR, 1.06 [95% CI, 0.71-1.62]). There is no significant statistical difference of death at 90 days (13.2% vs. 10.4%, p = 0.364). Conclusion: Reperfusion therapy could apply patients with mild first symptoms experience ND after hospitalization and expect similar prognosis compared to those without ND before the treatment.

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Abstract TP353: Use of Telestroke in a Metropolitan Stroke Code Process

Stroke ◽

10.1161/str.44.suppl_1.atp353 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Amy Castle ◽

Lana Stein ◽

Sandra Hanson ◽

Charles Ormiston ◽

Karen Porth

Keyword(s):

Emergency Department ◽

Ischemic Stroke ◽

Decision Tree ◽

Acute Ischemic Stroke ◽

Early Treatment ◽

Reperfusion Therapy ◽

Limited Knowledge ◽

Code Process ◽

Metropolitan Hospital ◽

Risk Of Treatment

BACKGROUND: Reperfusion therapy is the most important recent advance in early treatment for acute ischemic stroke, but remains underused and the timing of administration of treatment continues to be unacceptably delayed. The complexity of the decision tree and risk of treatment may be limiting use in the emergency department (ED) when those directing the therapy have limited knowledge and less comfort with administration of the drug. This review supports the hypothesis that utilizing telestroke to increase the Stroke Neurology expertise early in the stroke code in an organized stroke code process in a metropolitan hospital ED will improve the rate of use of reperfusion therapy and decrease the door-to-drug (DTD) times. METHODS and RESULTS: Telestroke was used to allow for Stroke Neurology presence and leadership in a redesigned stroke code process at 2 busy metropolitan hospitals beginning in 2009 at St. Joseph’s Hospital and 2010 at St. John’s Hospital. CONCLUSION: Telemedicine run stroke codes in a busy metropolitan ED resulted in increased use of reperfusion therapy and dramatic decreases in DTD times.

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Value of pre-intervention computed tomography perfusion imaging in the assessment of tissue outcome and long-term clinical prognosis in patients with anterior circulation acute ischemic stroke receiving reperfusion therapy: a systematic review

Acta Radiologica ◽

10.1177/02841851211035892 ◽

2021 ◽

pp. 028418512110358

Author(s):

Anubhav Katyal ◽

Sonu Menachem Maimonides Bhaskar

Keyword(s):

Computed Tomography ◽

Systematic Review ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Reperfusion Therapy ◽

Imaging Biomarkers ◽

Cochrane Central Register ◽

Clinical Prognosis ◽

Computed Tomography Perfusion

Background Computed tomography perfusion (CTP) imaging has emerged as an important adjunct to the current armamentarium of acute ischemic stroke (AIS) workflow. However, its adoption in routine clinical practice is far from optimal. Purpose To investigate the putative association of CTP imaging biomarkers in the assessment of prognosis in acute ischemic stroke. Material and Methods We performed a systematic review of the literature using MEDLINE, EMBASE, and Cochrane Central Register of Clinical Trials focusing on CTP biomarkers, tissue-based and clinical-based patient outcomes. We included randomized controlled trials, prospective cohort studies, and case-controlled studies published from January 2005 to 28 August 2020. Two independent reviewers conducted the study appraisal, data extraction, and quality assessment of the studies. Results A total of 60 full-text studies were included in the final systematic review analysis. Increasing infarct core volume is associated with reduced odds of achieving functional independence (modified Rankin score 0–2) at 90 days and is correlated with the final infarct volume when reperfusion is achieved. Conclusion CTP has value in assessing tissue perfusion status in the hyperacute stroke setting and the long-term clinical prognosis of patients with AIS receiving reperfusion therapy. However, the prognostic use of CTP requires optimization and further validation.

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