Reperfusion therapy in acute ischemic stroke - intravenous thrombolysis

Background and Purpose: We aimed to investigate the relationship between early NT-proBNP (N-terminal probrain natriuretic peptide) and all-cause death in patients receiving reperfusion therapy, including intravenous thrombolysis and endovascular thrombectomy (EVT). Methods: This study included 1039 acute ischemic stroke patients with early NT-proBNP data at 2 hours after the beginning of alteplase infusion for those with intravenous thrombolysis only or immediately at the end of EVT for those with EVT. We performed natural log transformation for NT-proBNP (Ln(NT-proBNP)). Malignant brain edema was ascertained by using the SITS-MOST (Safe Implementation of Thrombolysis in Stroke-Monitoring Study) criteria. Results: Median serum NT-proBNP level was 349 pg/mL (interquartile range, 89–1250 pg/mL). One hundred twenty-one (11.6%) patients died. Malignant edema was observed in 78 (7.5%) patients. Ln(NT-proBNP) was independently associated with 3-month mortality in patients with intravenous thrombolysis only (odds ratio, 1.465 [95% CI, 1.169–1.836]; P =0.001) and in those receiving EVT (odds ratio, 1.563 [95% CI, 1.139–2.145]; P =0.006). The elevation of Ln(NT-proBNP) was also independently associated with malignant edema in patients with intravenous thrombolysis only (odds ratio, 1.334 [95% CI, 1.020–1.745]; P =0.036), and in those with EVT (odds ratio, 1.455 [95% CI, 1.057–2.003]; P =0.022). Conclusions: An early increase in NT-proBNP levels was related to malignant edema and stroke mortality after reperfusion therapy.

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Neuroimaging Prediction of Hemorrhagic Transformation for Acute Ischemic Stroke

Cerebrovascular Diseases ◽

10.1159/000521150 ◽

2022 ◽

pp. 1-11

Author(s):

Lan Hong ◽

Tzu-Ming Hsu ◽

Yiran Zhang ◽

Xin Cheng

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Time Window ◽

Treatment Strategies ◽

Onset Time ◽

Intravenous Thrombolysis ◽

Reperfusion Therapy ◽

Hemorrhagic Transformation ◽

Advanced Technology ◽

Future Research

Background: Hemorrhagic transformation (HT) is a common complication of acute ischemic stroke, often resulting from reperfusion therapy. Early prediction of HT can enable stroke neurologists to undertake measures to avoid clinical deterioration and make optimal treatment strategies. Moreover, the trend of extending the time window for reperfusion therapy (both for intravenous thrombolysis and endovascular treatment) further requires more precise detection of HT tendency. Summary: In this review, we summarized and discussed the neuroimaging markers of HT prediction of acute ischemic stroke patients, mainly focusing on neuroimaging markers of ischemic degree and neuroimaging markers of blood-brain barrier permeability. This review is aimed to provide a concise introduction of HT prediction and to elicit possibilities of future research combining advanced technology to improve the accessibility and accuracy of HT prediction under emergent clinical settings. Key Messages: Substantial studies have utilized neuroimaging, blood biomarkers, and clinical variables to predict HT occurrence. Although huge progress has been made, more individualized and precise HT prediction using simple and robust imaging predictors combining stroke onset time should be the future goal of development.

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Disentangling Sex Differences in Use of Reperfusion Therapy in Patients With Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.119.028589 ◽

2020 ◽

Vol 51 (8) ◽

pp. 2332-2338

Author(s):

Jeppe Mainz ◽

Grethe Andersen ◽

Jan Brink Valentin ◽

Martin Faurholdt Gude ◽

Søren Paaske Johnsen

Keyword(s):

Sex Differences ◽

Ischemic Stroke ◽

Time Delay ◽

Acute Ischemic Stroke ◽

Emergency Medical Services ◽

Symptom Onset ◽

Odds Ratio ◽

Stroke Unit ◽

Intravenous Thrombolysis ◽

Reperfusion Therapy

Background and Purpose: Previous studies from local settings have reported that women with acute ischemic stroke have a lower chance of receiving reperfusion therapy treatment, including intravenous thrombolysis and thrombectomy, than men, but the underlying mechanisms of this disparity have not been identified. We aimed to examine sex differences in the utilization of reperfusion therapy focusing on all the phases of pre- and in-hospital time delay in a nationwide population-based cohort. Methods: This study was based on data from nationwide public registries. The study population included patients aged at least 18 years admitted with acute ischemic stroke using emergency medical services in Denmark dispatched after an emergency call in the period 2016 to 2017. Study outcomes included time delays from symptom onset to start of reperfusion therapy and use of reperfusion therapy. Data were analyzed using multivariable quantile regression and logistic regression. Results: A total of 5356 stroke events fulfilled the inclusion criteria. Women (26.6%) were less likely to receive intravenous thrombolysis than men (30.2 %), corresponding to an unadjusted odds ratio of 0.84 (95% CI, 0.74–0.95). In addition, women experienced a 20 minutes longer median time delay from stroke symptom onset to stroke unit arrival than men. Adjusting for onset-to-door time only appeared to have a limited effect on the sex differences in use of intravenous thrombolysis, whereas the odds ratio was 1.06 (95% CI, 0.93–1.21) when adjusting for age at stroke, stroke severity, and cohabitation status. No sex difference was observed for the use of thrombectomy. Conclusions: Women received less reperfusion therapy than men and had a longer time delay from symptom onset to stroke unit arrival, primarily due to a longer delay from symptom onset to emergency medical services call. These differences appeared to be due to the higher age and the higher proportion of women living alone at the time of the stroke.

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The Natural History and Reperfusion Therapy Outcomes of Acute Ischemic Stroke due to Isolated M2 Occlusions

BioMed Research International ◽

10.1155/2021/6626604 ◽

2021 ◽

Vol 2021 ◽

pp. 1-8

Author(s):

Hongmin Gong ◽

Libo Zhao ◽

Ge Tang ◽

Yu Chen ◽

Deyu Yang ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Infarct Volume ◽

Intravenous Thrombolysis ◽

Reperfusion Therapy ◽

Neurological Deficits ◽

Good Outcome ◽

Symptomatic Intracerebral Hemorrhage ◽

Efficacy Outcome ◽

The Difference

Objective. Currently, the standard treatment modality for patients with acute ischemic stroke (AIS) presenting with isolated M2 occlusions is not specific. We therefore assessed the difference in treatment outcomes for patients with isolated M2 occlusions. Methods. We retrospectively analyzed consecutive patients with AIS presenting with isolated M2 occlusions from October 1, 2018, to June 30, 2020. Patients were divided into 3 groups based on the treatments they received: no reperfusion therapy (NRT), intravenous thrombolysis treatment (IVT), and endovascular intervention (EVT), which comprised IVT in conjunction with EVT or EVT alone. The primary outcomes were improvements in modified Rankin Scale (mRS) scores at 90 days and National Institutes of Health Stroke Scale (NIHSS) scores at 24 hours after treatment compared with the baseline. The secondary efficacy outcome comprised a good outcome rate defined as a 90 − day mRS score ≤ 2 , final infarct volume (FIV), 90-day mortality rate, and successful recanalization rate, which was defined as a modified thrombolysis in cerebral infarction score ≥ 2 b . Safety outcomes included symptomatic intracerebral hemorrhage and procedure-related complications. Results. Seventy patients were enrolled and divided into 3 groups: the NRT group ( n = 25 ), IVT group ( n = 27 ), and EVT group ( n = 18 ). Twenty-four-hour posttreatment NIHSS scores were substantially decreased by EVT compared with NRT (adjusted β -4.01, 95% confidence interval [CI] -6.60 to -1.43; P = 0.003 ) or IVT (adjusted β , -3.61 [95% CI, -6.45 to -0.77]; P = 0.013 ). Compared with the outcomes observed after NRT, patients who received EVT were more likely to achieve lower 90-day mRS scores (adjusted β , -1.42 [95% CI, -2.66 to -0.63]; P = 0.007 ), higher good outcome rates (adjusted odds ratio, 8.73 [95% CI, 1.43-53.24]; P = 0.019 ), and smaller FIVs (adjusted β , -29.66 [95% CI, -59.73 to 0.42]; P = 0.048 ). The recanalization rate of EVT was high (88.89%), and procedure-related complications were rare (5.56%). Conclusions. For acute, isolated M2 occlusions, EVT could dramatically and rapidly improve neurological deficits with high safety and effectiveness. These changes were observed at 24 hours after treatment and were maintained over the long term.

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Thrombolysis in Acute Stroke

10.5772/intechopen.101252 ◽

2021 ◽

Author(s):

Mustafa Çetiner

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Reperfusion Therapy ◽

Clinical Findings ◽

Stroke Patients ◽

Acute Ischemic Stroke Patient ◽

Patient Selection Criteria ◽

Neuroimaging Techniques

The first step in stroke care is early detection of stroke patients and recanalization of the occluded vessel. Rapid and effective revascularization is the cornerstone of acute ischemic stroke management. Intravenous thrombolysis is the only approved pharmacological reperfusion therapy for patients with acute ischemic stroke. Patient selection criteria based on patient characteristics, time, clinical findings and advanced neuroimaging techniques have positively affected treatment outcomes. Recent studies show that the presence of salvageable brain tissue can extend the treatment window for intravenous thrombolysis and that these patients can be treated safely. Recent evidence provides stronger support for another thrombolytic agent, tenecteplase, as an alternative to alteplase. Endovascular thrombectomy is not a contraindication for intravenous thrombolysis. Evidence shows that the bridging approach provides better clinical outcomes. It is seen that intravenous thrombolysis is beneficial in stroke patients, whose symptom onset is not known, after the presence of penumbra tissue is revealed by advanced neuroimaging techniques. Reperfusion therapy with intravenous thrombolysis is beneficial in selected pregnant stroke patients. Pregnancy should not be an absolute contraindication for thrombolysis therapy. This chapter aims to review only the current evaluation of intravenous thrombolytic therapy, one of the reperfusion therapies applied in the acute phase of stroke.

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Abstract 157: High Systolic Blood Pressure Variability After Successful Reperfusion Therapy in Acute Ischemic Stroke Predicts Unfavorable Outcomes

Stroke ◽

10.1161/str.51.suppl_1.157 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Satoshi Hosoki ◽

Kaori Miwa ◽

Takeshi Yoshimoto ◽

Kanta Tanaka ◽

Hajime Ikenouchi ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Systolic Blood Pressure ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Blood Pressure Variability ◽

Intravenous Thrombolysis ◽

Reperfusion Therapy ◽

High Systolic Blood Pressure ◽

Systolic Blood Pressure Variability

Introduction: There has been increasing evidence that higher systolic blood pressure variability (SBPV) is related to unfavorable outcomes in patients with stroke. We explored the relation between SBPV and clinical outcomes after reperfusion therapy; intravenous thrombolysis (IVT) and endovascular therapy (EVT). Methods: We retrieved data of consecutive patients with acute ischemic stroke (AIS) treated with reperfusion therapy from our prospective stroke registry between October 2005 and December 2018. We calculated the following five SBPV during 24 hours after IVT or EVT; mean, standard deviation (SD), coefficient of variation (CV), successive variation (SV), and average real variability (ARV). Clinical outcomes included unfavorable outcomes as modified Rankin Scale (mRS) score 3-6 at 3 months and symptomatic intracranial hemorrhage (sICH) as any hemorrhage with neurological deterioration of 4 points of more on the National Institute of Health Stroke Scale (NIHSS). Successful reperfusion was indicated with early neurological improvements of 4 points of more on the NIHSS after IVT alone or Thrombolysis in Cerebral Infarction scores of 2b or 3 after EVT alone or EVT combined with IVT. Results: Among 933 patients with premorbid mRS scores of 0-1 (72±12 years; 316 women), 426 patients with unfavorable outcomes and 35 patients with sICH were observed. In adjusted analyses, all measures of SBPV but CV were related to unfavorable outcomes, while all measures of SBPV but mean SBP were related to sICH. In 566 patients with successful reperfusion, 228 patients with unfavorable outcomes and 10 patients with sICH were observed. In adjusted analyses, all measures of SBPV but mean SBP were positively related to unfavorable outcomes, while no measures of SBPV were independently related to sICH (table). Conclusion: High SBPV after successful reperfusion therapy contributed to unfavorable outcomes, suggesting high SBPV after reperfusion therapy might need more attention.

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