Acute Management Should Be Optimized in Patients with Less Specific Stroke Symptoms: Findings from a Retrospective Observational Study

Anterior circulation stroke (ACS) is associated with typical symptoms, while posterior circulation stroke (PCS) may cause a wide spectrum of less specific symptoms. We aim to assess the correlation between the initial presentation of acute ischemic stroke (AIS) symptoms and the treatment timeline. Using a retrospective, observational, single-center study, the set consists of 809 AIS patients treated with intravenous thrombolysis (IVT) and/or endovascular treatment (EVT). We investigate the impact of baseline clinical AIS symptoms and the affected vascular territory on recanalization times in patients treated with IVT only and EVT (±IVT). Regarding the IVT-only group, increasing the National Institutes of Health Stroke Scale (NIHSS) score on admission and speech difficulties are associated with shorter (by 1.59 ± 0.76 min per every one-point increase; p = 0.036, and by 24.56 ± 8.42 min; p = 0.004, respectively) and nausea/vomiting with longer (by 43.72 ± 13.13 min; p = 0.001) onset-to-needle times, and vertigo with longer (by 8.58 ± 3.84 min; p = 0.026) door-to-needle times (DNT). Regarding the EVT (±IVT) group, coma is associated with longer (by 22.68 ± 6.05 min; p = 0.0002) DNT, anterior circulation stroke with shorter (by 47.32 ± 16.89 min; p = 0.005) onset-to-groin time, and drooping of the mouth corner with shorter (by 20.79 ± 6.02 min; p = 0.0006) door-to-groin time. Our results demonstrate that treatment is initiated later in strokes with less specific symptoms than in strokes with typical symptoms.

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Endovascular Therapy versus Thrombolysis in Patients with Mild Strokes and Large Vessel Occlusions within the Anterior Circulation

Interventional Neurology ◽

10.1159/000489708 ◽

2018 ◽

Vol 7 (6) ◽

pp. 431-438 ◽

Cited By ~ 2

Author(s):

Andreas Kastrup ◽

Freimuth Brunner ◽

Helmut Hildebrandt ◽

Christian Roth ◽

Michael Winterhalter ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Clinical Results ◽

National Institutes Of Health ◽

Large Vessel ◽

Intracranial Hemorrhages ◽

Anterior Circulation ◽

Treatment Groups ◽

Good Outcome ◽

Discharge Rates

Background: In patients with large vessel occlusions, endovascular treatment (ET) has been shown to be superior to intravenous thrombolysis (IVT) in recent trials. However, it is currently unclear if patients with mild strokes also benefit from ET. Methods: We compared the discharge rates of good outcome (modified Rankin scale [mRS] ≤2), very good outcome (mRS 0–1), symptomatic intracranial hemorrhages (SICH), and infarct sizes in patients with mild strokes (admission National Institutes of Health Stroke Scale ≤10) and distal intracranial carotid artery, M1, and M2 occlusions during two time periods. Results: From 1/2008 to 10/2012 160 patients (mean age: 72 ± 12 years) were treated with IVT, and from 11/2012 to 11/2016 145 patients (mean age: 71 ± 13 years,) received ET with or without IVT. The clinical results were comparable between both treatment groups (59% after ET vs. 56% after IVT, p = 0.5 for an mRS 0–2) and (38% after ET vs. 32% after IVT, p = 0.3 for an mRS 0–1). In the subgroup of patients with an mRS ≤6, the early outcome did not differ significantly between ET and IVT either. The rates of SICH as well as the infarct sizes were not significantly different after ET compared with IVT. Conclusion: Compared with IVT, the routine use of ET did not significantly improve the early clinical or radiological outcome in patients with mild strokes and anterior circulation large vessel occlusions. Further randomized trials are urgently needed to determine the role of ET in this cohort.

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Rescue of Neglect and Language Impairment After Stroke Thrombectomy

Stroke ◽

10.1161/strokeaha.121.034243 ◽

2021 ◽

Author(s):

Shashvat M. Desai ◽

Konark Malhotra ◽

Guru Ramaiah ◽

Daniel A. Tonetti ◽

Waqas Haq ◽

...

Keyword(s):

Clinical Outcomes ◽

Language Impairment ◽

Functional Independence ◽

National Institutes Of Health ◽

Large Vessel ◽

Lower Mortality ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

The Impact

BACKGROUND AND PURPOSE: Although National Institutes of Health Stroke Scale scores provide an objective measure of clinical deficits, data regarding the impact of neglect or language impairment on outcomes after mechanical thrombectomy (MT) is lacking. We assessed the frequency of neglect and language impairment, rate of their rescue by MT, and impact of rescue on clinical outcomes. Methods: This is a retrospective analysis of a prospectively collected database from a comprehensive stroke center. We assessed right (RHS) and left hemispheric strokes (LHS) patients with anterior circulation large vessel occlusion undergoing MT to assess the impact of neglect and language impairment on clinical outcomes, respectively. Safety and efficacy outcomes were compared between patients with and without rescue of neglect or language impairment. Results: Among 324 RHS and 210 LHS patients, 71% of patients presented with neglect whereas 93% of patients had language impairment, respectively. Mean age was 71±15, 56% were females, and median National Institutes of Health Stroke Scale score was 16 (12–20). At 24 hours, MT resulted in rescue of neglect in 31% of RHS and rescue of language impairment in 23% of LHS patients, respectively. RHS patients with rescue of neglect (56% versus 34%, P <0.001) and LHS patients with rescue of language impairment (64 % versus 25%, P <0.01) were observed to have a higher rate of functional independence compared to patients without rescue. After adjusting for confounders including 24-hour National Institutes of Health Stroke Scale, rescue of neglect among RHS patients was associated with functional independence ( P =0.01) and lower mortality ( P =0.01). Similarly, rescue of language impairment among LHS patients was associated with functional independence ( P =0.02) and lower mortality ( P =0.001). ConclusionS: Majority of LHS-anterior circulation large vessel occlusion and of RHS-anterior circulation large vessel occlusion patients present with the impairment of language and neglect, respectively. In comparison to 24-hour National Institutes of Health Stroke Scale, rescue of these deficits by MT is an independent and a better predictor of functional independence and lower mortality.

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Endovascular Therapy vs. Thrombolysis in Pre-stroke Dependent Patients With Large Vessel Occlusions Within the Anterior Circulation

Frontiers in Neurology ◽

10.3389/fneur.2021.666596 ◽

2021 ◽

Vol 12 ◽

Author(s):

Andreas Kastrup ◽

Christian Roth ◽

Maria Politi ◽

Maria Alexandrou ◽

Helmut Hildebrandt ◽

...

Keyword(s):

Randomized Trials ◽

Intravenous Thrombolysis ◽

Treatment Modalities ◽

Hospital Death ◽

Anterior Circulation ◽

The Past ◽

Poor Outcome ◽

Symptomatic Intracranial Hemorrhage ◽

The Impact ◽

Case Basis

Background: In the past few years, several randomized trials have clearly shown that endovascular treatment (ET) in addition to intravenous thrombolysis (IVT) is superior to IVT alone in patients with proximal cerebral arterial occlusions. However, the effectiveness of ET in pre-stroke dependent patients (modified Rankin Scale ≥3) is uncertain.Methods: Using our prospectively obtained stroke database, we analyzed the impact of pre-stroke dependence on the rates of poor outcome (discharge mRS 5–6), in-hospital death, infarct sizes, and symptomatic intracranial hemorrhage (SICH) in patients with distal intracranial carotid artery M1 and M2 occlusions during two time periods.Results: From 1/2008 to 10/2012, a total of 544 patients (455 without and 89 with dependence) were treated with IVT, and from 11/2012 to 12/2019 a total of 1,061 patients (919 without and 142 with dependence) received ET (with or without IVT). Irrespective of the treatment modality, the dependent patients had significantly higher rates of poor outcome (55 vs. 32%, p < 0.001), death (24 vs. 11%; p < 0.001), or SICH (8.2 vs. 3.6%, p < 0.01) than independent patients. In dependent patients, ET significantly reduced the rates of poor outcome (49 vs. 64%, p < 0.01) and led to smaller infarcts, whereas the rates of in-hospital death (25 vs. 22%; p = 0.6) or SICH (8.5 vs. 7.9%, p = 0.9) were comparable between both treatment modalities.Conclusions: Compared with IVT, ET avoids poor outcome and leads to smaller infarcts in dependent patients. However, the overall high rates of poor outcome in this patient population stress the importance to perform decisions based on a case-by-case basis.

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Endovascular Mechanical Recanalisation After Intravenous Thrombolysis in Acute Anterior Circulation Stroke: The Impact of a New Temporary Stent

CardioVascular and Interventional Radiology ◽

10.1007/s00270-011-0317-5 ◽

2011 ◽

Vol 35 (6) ◽

pp. 1326-1331 ◽

Cited By ~ 8

Author(s):

Gunther Fesl ◽

Maximilian Patzig ◽

Markus Holtmannspoetter ◽

Thomas E. Mayer ◽

Thomas Pfefferkorn ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Anterior Circulation ◽

Mechanical Recanalisation ◽

The Impact ◽

Temporary Stent

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Door-to-Needle Time in Acute Stroke Treatment and the “July Effect”

The Neurohospitalist ◽

10.1177/1941874417733108 ◽

2017 ◽

Vol 8 (1) ◽

pp. 24-28 ◽

Cited By ~ 2

Author(s):

Maximiliano A. Hawkes ◽

Federico Carpani ◽

Mauricio F. Farez ◽

Sebastian F. Ameriso

Keyword(s):

Intravenous Thrombolysis ◽

National Institutes Of Health ◽

Teaching Hospitals ◽

Intracranial Hemorrhages ◽

Time Rate ◽

Stroke Outcomes ◽

Stroke Treatment ◽

July Effect ◽

The Impact ◽

Academic Year

Intravenous thrombolysis improves outcomes in acute ischemic stroke in a time-dependent fashion. As in teaching hospitals, clinical outcomes may worsen due to the arrival of new inexperienced house staff early in the academic year (July effect, JE), we evaluated the impact of the “JE” on the door-to-needle time for intravenous thrombolysis and other stroke outcomes. In this retrospective cohort study, we assessed all acute ischemic strokes treated with intravenous thrombolysis between July 2003 and June 2016. Among 101 patients, there was no detrimental July effect on the door-to-needle time, rate of thrombolysis within 60 minutes of arrival, thrombolysis of stroke mimics, post-thrombolysis intracranial hemorrhages, National Institutes of Health Stroke Scale, and modified Rankin Scale outcomes.

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Delayed Neurological Improvement After Full Endovascular Reperfusion in Acute Anterior Circulation Ischemic Stroke

Stroke ◽

10.1161/strokeaha.120.032066 ◽

2021 ◽

Author(s):

Blanca Talavera ◽

Beatriz Gómez-Vicente ◽

Mario Martínez-Galdámez ◽

Elena López-Cancio ◽

Carmen García-Cabo ◽

...

Keyword(s):

Ischemic Stroke ◽

Cerebral Infarction ◽

Odds Ratio ◽

Intravenous Thrombolysis ◽

Functional Independence ◽

National Institutes Of Health ◽

Anterior Circulation ◽

Neurological Improvement ◽

Male Sex

Background and Purpose: We aimed to determine the prevalence and predictors of delayed neurological improvement (DNI) after complete endovascular reperfusion in anterior circulation acute ischemic stroke (AIS). Methods: Retrospective analysis of an online multicenter prospective reperfusion registry of patients with consecutive anterior circulation AIS treated with endovascular thrombectomy (EVT) from January 2018 to June 2019 in tertiary stroke centers of the NORDICTUS (NORD-Spain Network for Research and Innovation in ICTUS) network. We included patients with AIS with a proximal occlusion in whom a modified Thrombolysis in Cerebral Infarction 3 reperfusion pattern was obtained. DNI was defined if, despite absence of early neurological improvement during the first 24 hours, patients achieved functional independence on day 90. Clinical and radiological variables obtained before EVT were analyzed as potential predictors of DNI. Results: Of 1565 patients with consecutive AIS treated with EVT, 1381 had proximal anterior circulation occlusions, 803 (58%) of whom achieved a modified Thrombolysis in Cerebral Infarction 3. Of these, 628 patients fulfilled all selection criteria and were included in the study. Mean age was 73.8 years, 323 (51.4%) were female, and median baseline National Institutes of Health Stroke Scale was 16. Absence of early neurological improvement was observed in 142 (22.6%) patients; 32 of these (22.5%) achieved good long-term outcome and constitute the DNI group. Predictors of DNI in multivariable-adjusted logistic regression were male sex (odds ratio, 6.4 [95% CI, 2.1–22.3] P =0.002), lower pre-EVT National Institutes of Health Stroke Scale score (odds ratio, 1.4 [95% CI, 1.2–1.5], P <0.001), and intravenous thrombolysis (odds ratio, 9.1 [95% CI, 2.7–30.90], P <0.001). Conclusions: One-quarter of patients with anterior circulation AIS who do not clinically improve within the first 24 hours after complete cerebral endovascular recanalization will achieve long-term functional independence, regardless of the poor early clinical course. Male sex, lower initial clinical severity, and use of intravenous thrombolysis before EVT predicted this clinical pattern.

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Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?

Cerebrovascular Diseases ◽

10.1159/000468995 ◽

2017 ◽

Vol 43 (5-6) ◽

pp. 305-312 ◽

Cited By ~ 22

Author(s):

Cyril Dargazanli ◽

Arturo Consoli ◽

Benjamin Gory ◽

Raphaël Blanc ◽

Julien Labreuche ◽

...

Keyword(s):

Ischaemic Stroke ◽

Favourable Outcome ◽

National Institutes Of Health ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Excellent Outcome ◽

Mild Stroke ◽

The Impact

Background: In population-based studies, patients presenting with minor or mild stroke symptoms represent about two-thirds of stroke patients, and almost one-third of these patients are unable to ambulate independently at the time of discharge. Although mechanical thrombectomy (MT) has become the standard of care for acute ischaemic stroke with proximal large vessel occlusion (LVO) in the anterior circulation, the management of patients harbouring proximal occlusion and minor-to-mild stroke symptoms has not yet been determined by recent trials. The purpose of this study was to evaluate the impact of reperfusion on clinical outcome in low National Institutes of Health Stroke Scale (NIHSS) patients treated with MT. Methods: We analysed 138 consecutive patients with acute LVO of the anterior circulation (middle cerebral artery M1 or M2 segment, internal carotid artery or tandem occlusion) with NIHSS <8, having undergone MT in 3 different centres. Reperfusion was graded using the modified thrombolysis in cerebral infarction (TICI) score and 3 grades were defined, ranging from failed or poor reperfusion (TICI 0, 1, 2A) to complete reperfusion (TICI 3). The primary clinical endpoint was an excellent outcome defined as a modified Rankin score (mRs) 0-1 at 3-months. The impact of reperfusion grade was assessed in univariate and multivariate analyses. The secondary endpoints included favourable functional outcome (90-day mRS 0-2), death and safety concerns. Results: Successful reperfusion was achieved in 81.2% of patients (TICI 2B, n = 47; TICI 3, n = 65). Excellent outcome (mRs 0-1) was achieved in 69 patients (65.0%) and favourable outcome (mRs ≤2) in 108 (78.3%). Death occurred in 7 (5.1%). Excellent outcome increased with reperfusion grades, with a rate of 34.6% in patients with failed/poor reperfusion, 61.7% in patients with TICI 2B reperfusion, and 78.5% in patients with TICI 3 reperfusion (p < 0.001). In multivariate analysis adjusted for patient characteristics associated with excellent outcome, the reperfusion grade remained significantly associated with an increase in excellent outcome; the OR (95% CI) was 3.09 (1.06-9.03) for TICI 2B and 6.66 (2.27-19.48) for TICI 3, using the failed/poor reperfusion grade as reference. Similar results were found regarding favourable outcome (90-day mRs 0-2) or overall mRS distribution (shift analysis). Conclusion: Successful reperfusion is strongly associated with better functional outcome among patients with proximal LVO in the anterior circulation and minor-to-mild stroke symptoms. Randomized controlled studies are mandatory to assess the benefit of MT compared with optimal medical management in this subset of patients.

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Multicenter experience with the new SOFIA Plus catheter as a primary local aspiration catheter for acute stroke thrombectomy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012812 ◽

2016 ◽

Vol 9 (12) ◽

pp. 1223-1227 ◽

Cited By ~ 27

Author(s):

M A Möhlenbruch ◽

C Kabbasch ◽

A Kowoll ◽

E Broussalis ◽

M Sonnberger ◽

...

Keyword(s):

Acute Stroke ◽

National Institutes Of Health ◽

Vascular Territory ◽

Procedure Time ◽

Thrombus Aspiration ◽

University Hospitals ◽

Anterior Circulation ◽

Nihss Score ◽

First Pass ◽

Stent Retrievers

IntroductionThe direct aspiration first pass technique (ADAPT) has been introduced as a rapid and safe endovascular treatment strategy in patients with ischemic stroke.ObjectiveTo determine the technical feasibility, safety, and functional outcome with ADAPT using the new large-bore 6F SOFIA Plus catheter.MethodsA retrospective analysis of prospectively collected data from six university hospitals was performed. The following parameters of all acute stroke procedures (June 2015– January 2016) using the SOFIA Plus catheter were analyzed: accessibility of the thrombus with the catheter, recanalization success (Thrombolysis in Cerebral Infarction ≥2b), time to recanalization, procedure-related complications. Furthermore, National Institutes of Health Stroke Scale (NIHSS) scores at presentation and discharge and the modified Rankin scale (mRS) score at 90 days were recorded.Results85 patients were treated using the SOFIA Plus catheter. The occlusion site was the anterior circulation in 94.1%. Median baseline NIHSS score was 18. In 64.7%, ADAPT alone was successful after a median procedure time of 21 min. With additional use of stent retrievers in the remaining cases, the recanalization rate was 96.5%. No catheter-related complications such as dissections were observed. Thrombus migration to a new vascular territory occurred in 4.7% and symptomatic hemorrhage in 4.7%. After 3 months, mRS 0–2 was achieved in 49.4%. Mortality rate was 20%.ConclusionsIn the majority of cases, thrombus aspiration using the SOFIA Plus catheter results in successful recanalization after a short procedure time. With additional use of stent retrievers, a high recanalization rate can be achieved (96.5%). The complication rate was in line with those of previous publications.

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Contemporary Trends in the Treatment of Mild Ischemic Stroke with Intravenous Thrombolysis: Paul Coverdell National Acute Stroke Program

Cerebrovascular Diseases ◽

10.1159/000517969 ◽

2021 ◽

pp. 1-7

Author(s):

Ganesh Asaithambi ◽

Xin Tong ◽

Sallyann M. Coleman King ◽

Mary G. George

Keyword(s):

Ischemic Stroke ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Intravenous Thrombolysis ◽

Estimating Equation ◽

National Institutes Of Health ◽

Generalized Estimating Equation ◽

Mild Stroke ◽

The Impact ◽

Program Data

Background: Presentation with mild symptoms is a common reason for intravenous thrombolysis (IVT) nonuse among acute ischemic stroke (AIS) patients. We examined the impact of IVT on the outcomes of mild AIS over time. Methods: Using the Paul Coverdell National Stroke Program data, we examined trends in IVT utilization from 2010 to 2019 among AIS patients presenting with National Institutes of Health Stroke Scale (NIHSS) scores ≤5. Outcomes adjudicated included rates of discharge to home and ability to ambulate independently at discharge. We used generalized estimating equation models to examine the effect of IVT on outcomes of AIS patients presenting with mild symptoms and calculated adjusted odds ratio (AOR) with 95% confidence intervals (CI). Results: During the study period, 346,762 patients presented with mild AIS symptoms. Approximately 6.2% were treated with IVT. IVT utilization trends increased from 3.7% in 2010 to 7.7% in 2019 (p < 0.001). Patients treated with IVT had higher median NIHSS scores upon presentation (IVT 3 [2, 4] vs. no IVT 2 [0, 3]). Rates of discharge to home (AOR 2.06, 95% CI: 1.99–2.13) and ability to ambulate at time of discharge (AOR 1.82, 95% CI: 1.76–1.89) were higher among those treated with IVT. Conclusion: There was an increased trend in IVT utilization among AIS patients presenting with mild symptoms. Utilization of IVT increased the odds of being discharged to home and the ability to ambulate at discharge independently in patients with mild stroke.

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A direct aspiration first pass technique with the new ARC catheter for thrombectomy of large vessel occlusion strokes: A multicenter study

Interventional Neuroradiology ◽

10.1177/1591019918803962 ◽

2018 ◽

Vol 25 (2) ◽

pp. 187-193 ◽

Cited By ~ 1

Author(s):

Pierre De Marini ◽

Sanjeev Nayak ◽

François Zhu ◽

Serge Bracard ◽

René Anxionnat ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

National Institutes Of Health ◽

Large Vessel ◽

University Hospitals ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Symptomatic Intracerebral Hemorrhage ◽

First Pass ◽

Scale Scores ◽

Reperfusion Rate

Background and purpose A direct aspiration first pass technique involves first-line aspiration to remove the thrombus through a large-bore aspiration catheter in large vessel strokes. The aim of this study was to assess safety and clinical outcomes with a direct aspiration first pass technique using the new ARC catheter. Methods A retrospective analysis of prospectively collected data from three university hospitals was performed between June 2016 and May 2018. The following parameters of all acute ischemic stroke interventions using the ARC catheter were analyzed: use of intravenous thrombolysis, National Institutes of Health Stroke Scale scores at presentation and discharge, successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b–3), procedure duration, procedure-related complications and 90-day clinical outcome (modified Rankin Scale score). Results In total, 41 patients were included in the study and anterior circulation occlusion was noted in 35 (85%). The median National Institutes of Health Stroke Scale at admission was 18 and prior intravenous thrombolysis was administered in 35 patients (85%). Only six (15%) patients required the use of a rescue stent retriever. Successful reperfusion was achieved in 40 patients (98%) with a median procedure time of 32 minutes. No catheter-related complications were observed. Symptomatic intracerebral hemorrhage occurred in one patient (2%). Median National Institutes of Health Stroke Scale at discharge was 3; 49% were independent and 10% died at 90 days. Conclusions In the present study, the ARC catheter allowed a 98% successful reperfusion rate. The complication rate was in line with those of previous a direct aspiration first pass technique publications.

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