scholarly journals Recent Advances in Thrombolysis and Thrombectomy in Acute Ischemic Stroke Treatment: Neurologist’s and Interventional Neuroradiologist’s Perspective

2021 ◽  
Author(s):  
Pinar Gelener ◽  
Süha Halil Akpinar
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Acute Treatment ◽  
Treatment Options ◽  
Randomized Control Trials ◽  
Stroke Treatment ◽  
Endovascular Methods ◽  
Randomized Control

As stroke is still the leading cause of disability and mortality worldwide, it is promising that there has been a significant change in the acute treatment options for the patients presenting with acute ischemic stroke over the last 23 years after the approval of alteplase. Vascular recanalization of the occluded artery by endovascular methods with or without thrombolysis has shown improved clinical outcomes, particularly after randomized control trials (RCTs), which were conducted between December 2010, and December 2014. These trials will be discussed in more detail the below following sections of this chapter. Successful emergency reperfusion conducted on time still remains the most important determinant of good clinical outcome.

scholarly journals Efficacy of Mechanical Thrombectomy using Penumbra ACETM Aspiration Catheter Compared to Stent Retriever SolitaireTM FR in Patients with Acute Ischemic Stroke

2021 ◽  
Vol 11 (4) ◽  
pp. 504
Author(s):  
Dalibor Sila ◽  
Markus Lenski ◽  
Maria Vojtková ◽  
Mustafa Elgharbawy ◽  
František Charvát ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Binary Logistic Regression ◽  
Stent Retriever ◽  
Good Clinical Outcome ◽  
Significant Difference ◽  
Aspiration Technique

Background: Mechanical thrombectomy is the standard therapy in patients with acute ischemic stroke (AIS). The primary aim of our study was to compare the procedural efficacy of the direct aspiration technique, using Penumbra ACETM aspiration catheter, and the stent retriever technique, with a SolitaireTM FR stent. Secondarily, we investigated treatment-dependent and treatment-independent factors that predict a good clinical outcome. Methods: We analyzed our series of mechanical thrombectomies using a SolitaireTM FR stent and a Penumbra ACETM catheter. The clinical and radiographic data of 76 patients were retrospectively reviewed. Using binary logistic regression, we looked for the predictors of a good clinical outcome. Results: In the Penumbra ACETM group we achieved significantly higher rates of complete vessel recanalization with lower device passage counts, shorter recanalization times, shorter procedure times and shorter fluoroscopy times (p < 0.001) compared to the SolitaireTM FR group. We observed no significant difference in good clinical outcomes (52.4% vs. 56.4%, p = 0.756). Predictors of a good clinical outcome were lower initial NIHSS scores, pial arterial collateralization on admission head CT angiography scan, shorter recanalization times and device passage counts. Conclusions: The aspiration technique using Penumbra ACETM catheter is comparable to the stent retriever technique with SolitaireTM FR regarding clinical outcomes.

Effect of age and baseline ASPECTS on outcomes in large-vessel occlusion stroke: results from the HERMES collaboration

2020 ◽  
pp. neurintsurg-2020-016621
Author(s):  
Johanna Maria Ospel ◽  
Manon Kappelhof ◽  
Nima Kashani ◽  
Bijoy K Menon ◽  
Bruce C V Campbell ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Effect Size ◽  
Point Estimate ◽  
Stroke Patients ◽  
Multiplicative Interaction ◽  
Size Estimates ◽  
Effect Of Age

BackgroundPatient age and baseline Alberta Stroke Program Early CT score (ASPECTS) are both independent predictors of outcome in acute ischemic stroke patients treated with endovascular therapy (EVT). We assessed the combined effect of age and ASEPCTS on clinical outcome in acute ischemic stroke patients with LVO with and without EVT, and EVT treatment effect in different age/ASPECTS subgroups.MethodsThe HERMES collaboration pooled data of seven randomized controlled trials that tested the efficacy of EVT. Adjusted logistic regression was performed to test for multiplicative interaction of age and ASPECTS with the primary outcome (ordinal mRS) and secondary outcomes (mRS 0–2/0–1/0–3) in the EVT and control arms. Patients were then stratified by age (<75 vs ≥75 years) and ASPECTS (0–5/6–7/8–10), and adjusted effect-size estimates for the association of EVT were derived for the six age/ASPECTS subgroups.Results1735 patients were included in the analysis. There was no multiplicative interaction between age and ASPECTS on clinical outcomes. In the exploratory subgroup analysis, we found a nominally negative point estimate for the association of EVT with clinical outcome in the ASPECTS 0–5/age ≥75, subgroup (acOR 0.36, 95% CI 0.07 to 1.89). The point estimate for moderate outcome (mRS0-3) nominally favored EVT (aOR 1.24, 95% CI 0.16 to 9.84). In all other subgroups, effect size-estimates consistently favored EVT.ConclusionThere was no multiplicative interaction of age and ASPECTS on clinical outcomes in EVT or control arm patients. Outcomes in patients ≥75 years with ASPECTS 0–5 were poor, irrespective of treatment. Further investigation to define the role of EVT and range of acceptable outcomes in this subgroup is warranted.

Patterns and Clinical Impact of Angiographically Visible Distal Emboli During Thrombectomy With Solitaire for Acute Ischemic Stroke

Neurosurgery ◽  
2015 ◽  
Vol 78 (2) ◽  
pp. 242-250 ◽  
Author(s):  
Marcus D. Mazur ◽  
Craig Kilburg ◽  
Min S. Park ◽  
Philipp Taussky
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Vascular Territory ◽  
Before And After ◽  
Unfavorable Clinical Outcome ◽  
Flow Restoration ◽  
Poor Outcomes

ABSTRACT BACKGROUND: Revascularization rates with stent retrievers after acute ischemic stroke are 69% to 86%, but favorable clinical outcomes occur in just 43% to 58% of cases. New distal emboli may negatively impact clinical outcomes. OBJECTIVE: To determine the prevalence and angiographic pattern of distal emboli associated with mechanical thrombectomy using the Solitaire Flow Restoration device and evaluate their correlation with clinical outcome. METHODS: We retrospectively reviewed the cerebral angiography of all patients with acute ischemic stroke who underwent mechanical thrombectomy with the use of the Solitaire FR device from 2012 to 2013. Angiographic microcatheter runs prior to Solitaire deployment and after thrombectomy were compared to identify new distal filling defects. Clinical outcome was assessed at discharge and after 90 days. RESULTS: Successful revascularization using the Solitaire device occurred in 36 of 39 patients (92%). Three distinct patterns were identified: new distal emboli in the same vascular territory (n = 3), new distal emboli in a new vascular territory (n = 3), and distal emboli that resolved after proximal revascularization (n = 7). Thirteen patients had distal emboli before and after Solitaire runs, and 13 showed no evidence of distal emboli. Favorable outcome (modified Rankin scores 0-2) was seen in 54% of all patients and 83% of patients with new distal emboli; thus, there was no correlation between new emboli and unfavorable clinical outcome (P = .67). CONCLUSION: We report an incidence rate of at least 15% of new emboli associated with use of the Solitaire device during thrombectomy in our series. Filling defects after Solitaire use were not associated with poor outcomes at discharge or 90-day follow-up.

Influence of Renal Function on Treatment Results after Stroke Thrombectomy

2017 ◽  
Vol 44 (5-6) ◽  
pp. 351-358 ◽  
Author(s):  
Mona Laible ◽  
Markus Alfred Möhlenbruch ◽  
Johannes Pfaff ◽  
Ekkehart Jenetzky ◽  
Peter Arthur Ringleb ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Multivariate Regression ◽  
Stroke Severity ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Stroke Treatment ◽  
Poor Outcome ◽  
Increased Risk

Background: Renal dysfunction (RD) may be associated with poor outcome in ischemic stroke patients treated with mechanical thrombectomy (MT), but data concerning this important and emerging comorbidity do not exist so far. Here, we investigated the influence of RD on postprocedural intracerebral hemorrhage (ICH), clinical outcome, and mortality in a large prospectively collected cohort of acute ischemic stroke patients treated with MT. Methods: Consecutive patients with anterior-circulation stroke treated with MT between October 2010 and January 2016 were included. RD was defined as glomerular filtration rate (GFR) <60 mL/min/1.73 m2. In a prospective database, clinical characteristics were recorded and brain images were analyzed for the presence of ICH after treatment in all patients. Clinical outcome was assessed by the modified Rankin Scale (mRS) after 3 months. To evaluate associations between clinical factors and outcomes uni- and multivariate regression analyses were conducted. Results: In total, 505 patients fulfilled all inclusion criteria (female: 49.7%, mean age: 71.0 years). RD at admission was present in 20.2%. RD patients were older and had cardiovascular risk factors more often. Multivariate regression analysis after adjustment for age, stroke severity, diabetes, hypertension, GFR, previous stroke, MT alone, or additional thrombolysis and recanalization results revealed that lower GFR was not independently associated with poor outcome (mRS 3-6; OR 1.13, 95% CI 0.99-1.28; p = 0.072) or ICH. However, lower GFR at admission was associated with a higher risk of mortality (OR 1.15, 95% CI 1.01-1.31; p = 0.038). Compared to admission, GFR values were higher at discharge (mean: 77.9 vs. 80.8 mL/min/1.73 m2; p = 0.046). Conclusions: We did not find evidence for an association of lower GFR with an increased risk of poor outcome and ICH, but lower GFR was a determinant of 90-day mortality after endovascular stroke treatment. Our findings encourage also performing MT in this relevant subgroup of acute ischemic stroke patients.

scholarly journals Potential link between post-acute ischemic stroke exposure to hypoglycemia and hemorrhagic transformation

2017 ◽  
Vol 15 (5) ◽  
pp. 477-483 ◽  
Author(s):  
Kyle D Klingbeil ◽  
Sebastian Koch ◽  
Kunjan R Dave
Keyword(s):  
Ischemic Stroke ◽  
Insulin Therapy ◽  
Acute Ischemic Stroke ◽  
Intensive Insulin Therapy ◽  
Treatment Options ◽  
Hemorrhagic Transformation ◽  
Stroke Treatment ◽  
Glucose Levels ◽  
Potential Link ◽  
Time Of Admission

Hemorrhagic transformation is a severe complication of acute ischemic stroke owing to its limited treatment options and poor prognosis. In the last decade, the rates of hemorrhagic transformation incidence have been associated with blood glucose levels. In particular, hyperglycemia at the time of admission has been associated with increased rates of hemorrhagic transformation in acute ischemic stroke patients. Recent pilot clinical trials have attempted to use intensive insulin therapy during stroke treatment to reduce the severity of cerebral infarction and possibly alleviate the risk of hemorrhagic transformation. However, the results of these studies have shown no clear clinical benefit. In addition, intensive insulin therapy has increased rates of hypoglycemia which may be associated with larger infarct growth. We hypothesize that hypoglycemia, similarly to hyperglycemia, is a risk factor for worse outcomes in acute ischemic stroke by promoting hemorrhagic transformation. This review serves to call attention to patterns present within intensive insulin therapy trials and shed light into the pathophysiological effects of hypoglycemia. It is critical that efforts be directed toward the prevention of hemorrhagic transformation by optimizing insulin therapy during the treatment of acute ischemic stroke.

scholarly journals Investigation of Recombinant Tissue Plasminogen Activator Complications in Treatment of patients with ischemic stroke visiting Vali-e-Asr hospital in Birjand, 2016-2017

2019 ◽  
Author(s):  
Hamid Reza Riasi ◽  
Elham Zarei ◽  
Forod Salehi ◽  
Fatemeh Sayehmiri
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Plasminogen Activator ◽  
Tissue Plasminogen Activator ◽  
Treatment Options ◽  
Recombinant Tissue Plasminogen Activator ◽  
Current Treatment ◽  
Fisher Exact Test ◽  
Stroke Treatment ◽  
Tissue Plasminogen

Abstract Background: Current treatment options for the sake of treating acute ischemic stroke include recombinant tissue plasminogen activator or dual anti platelet therapies. This study aims to evaluate the complications of recombinant tissue plasminogen activator in treatment of patients with ischemic stroke who were admitted in Vali-e-Asr hospital in Birjand, 2016-2017. Method: This descriptive analytic study was performed on patients with acute ischemic stroke who were admitted in neurology ward of Vali-e-Asr hospital in Birjand from 2016 to 2017. A total of 127 patients participated in this study. The data about complications of treatment were collected by questionnaires and entered into SPSS 21. Then, data were analyzed by Chi-square or Fisher exact test at a significant level of p≤ 0.5. Results: A total of 127 subjects received treatment for ischemic stroke. Thirty-one (24.4%) patients have been treated with recombinant tissue plasminogen activator and ninety-six (75.6%) have been treated conventionally with dual antiplatelet. These two groups were matched in terms of age and sex. The history of hypertension in the recombinant tissue plasminogen activator group and the conventional treatments were 32.3% and 67.7%, respectively (p=0.03). 99% of patients in the antiplatelet treatment group (N=96) and 96.8% of patients in the recombinant tissue plasminogen activator group (N=31) have been discharged and one death was occurred in each group (p=0.4). Regarding the incidence of recombinant tissue plasminogen activator complications, IVH was reported in two patients (6.5%, p = 0.06) Conclusion: The incidence of mortality was the same in two groups. Also, complications were only reported in two patients in the recombinant tissue plasminogen activator group (both intraventricular hemorrhage) and the difference was not statistically significant. Researchers recommend that more clinical trials must be conducted. If it is approved, the findings of the current studies will be widely taken into consideration for acute stroke treatment.

Evaluation of the clot burden score (cbs) for acute ischemic stroke (ais) in intent-to-treat patients.

2019 ◽  
Vol 1 (1) ◽  
pp. 11-15 ◽  
Author(s):  
Sarah Yaziz ◽  
Ahmad Sobri Muda ◽  
Wan Asyraf Wan Zaidi ◽  
Nik Azuan Nik Ismail
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Predictive Value ◽  
Area Under The Curve ◽  
Rank Correlation ◽  
Treatment Decision ◽  
Roc Curves ◽  
Significant Negative Correlation ◽  
Clot Burden

Background : The clot burden score (CBS) is a scoring system used in acute ischemic stroke (AIS) to predict patient outcome and guide treatment decision. However, CBS is not routinely practiced in many institutions. This study aimed to investigate the feasibility of CBS as a relevant predictor of good clinical outcome in AIS cases. Methods:  A retrospective data collection and review of AIS patients in a teaching hospital was done from June 2010 until June 2015. Patients were selected following the inclusion and exclusion criteria. These patients were followed up after 90 days of discharge. The Modified Rankin scale (mRS) was used to assess their outcome (functional status). Linear regression Spearman Rank correlation was performed between the CBS and mRS. The quality performance of the correlations was evaluated using Receiver operating characteristic (ROC) curves. Results: A total of 89 patients with AIS were analysed, 67.4% (n=60) male and 32.6% (n=29) female. Twenty-nine (29) patients (33.7%) had a CBS ?6, 6 patients (6.7%) had CBS <6, while 53 patients (59.6%) were deemed clot free. Ninety (90) days post insult, clinical assessment showed that 57 (67.6%) patients were functionally independent, 27 (30.3%) patients functionally dependent, and 5 (5.6%) patients were deceased. Data analysis reported a significant negative correlation (r= -0.611, p<0.001). ROC curves analysis showed an area under the curve of 0.81 at the cut-off point of 6.5. This showed that a CBS of more than 6 predicted a good mRS clinical outcome in AIS patients; with sensitivity of 98.2%, specificity of 53.1%, positive predictive value (PPV) of 76%, and negative predictive value (NPV) of 21%. Conclusion: CBS is a useful additional variable for the management of AIS cases, and should be incorporated into the routine radiological reporting for acute ischemic stroke (AIS) cases.

Association between Blood Urea Nitrogen-to-creatinine Ratio and Three-Month Outcome in Patients with Acute Ischemic Stroke

2019 ◽  
Vol 16 (2) ◽  
pp. 166-172 ◽  
Author(s):  
Linghui Deng ◽  
Changyi Wang ◽  
Shi Qiu ◽  
Haiyang Bian ◽  
Lu Wang ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Blood Urea Nitrogen ◽  
Univariate Analysis ◽  
Density Lipoprotein ◽  
Hydration Status ◽  
Creatinine Ratio ◽  
Urea Nitrogen

Background: Hydration status significantly affects the clinical outcome of acute ischemic stroke (AIS) patients. Blood urea nitrogen-to-creatinine ratio (BUN/Cr) is a biomarker of hydration status. However, it is not known whether there is a relationship between BUN/Cr and three-month outcome as assessed by the modified Rankin Scale (mRS) score in AIS patients. Methods: AIS patients admitted to West China Hospital from 2012 to 2016 were prospectively and consecutively enrolled and baseline data were collected. Poor clinical outcome was defined as three-month mRS > 2. Univariate and multivariate logistic regression analyses were performed to determine the relationship between BUN/Cr and three-month outcome. Confounding factors were identified by univariate analysis. Stratified logistic regression analysis was performed to identify effect modifiers. Results: A total of 1738 patients were included in the study. BUN/Cr showed a positive correlation with the three-month outcome (OR 1.02, 95% CI 1.00-1.03, p=0.04). However, after adjusting for potential confounders, the correlation was no longer significant (p=0.95). An interaction between BUN/Cr and high-density lipoprotein (HDL) was discovered (p=0.03), with a significant correlation between BUN/Cr and three-month outcome in patients with higher HDL (OR 1.03, 95% CI 1.00-1.07, p=0.04). Conclusion: Elevated BUN/Cr is associated with poor three-month outcome in AIS patients with high HDL levels.

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

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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