Local intraarterial tirofiban after formation of anterograde flow in patients with acute ischemic stroke: Preliminary experience and short term follow-up results

Objective

Despite the risk of intracranial hemorrhage, combination therapy with intravenous recombinant tissue plasminogen activator and intraarterial mechanical thrombolysis can be effective for treatment of acute ischemic stroke. We investigated the feasibility and safety of intraarterial tirofiban following formation of anterograde flow after mechanical thrombolysis in acute ischemic stroke.

Methods

We analyzed data from consecutive patients with acute ischemic stroke, who underwent treatment with intraarterial thrombolysis. All patients were evaluated immediately and 7 days later by computed tomography scanning and magnetic resonance imaging scanning with magnetic resonance angiography. For clinical outcome analysis, we followed up the NIHSS score and modified Rankin Scale score during a period of 3 months.

Results

Sixteen patients underwent treatment. The mean baseline NIHSS score was 16.1 ± 4.4 points. 75.1% of patients showed angiographic improvement; 43.8% and 31.3% had complete and partial recanalization, respectively. 53.3% and 56.3% showed clinical improvement and favorable outcome at 24 h and 3 months, respectively. One patient had symptomatic intracranial hemorrhage.

Conclusions

Our results suggest that administration of local intraarterial tirofiban after anterograde flow formation is a viable treatment strategy for patients of acute ischemic stroke for reducing the risk of reocclusion after intraarterial thrombolysis.     

Prognosis of aphasia in stroke patients early after iv thrombolysis

Objective

Stroke patients with aphasia have a high long-term morbidity. Intravenous rt-PA (iv) thrombolysis is given more deliberately to these patients. Early outcome data is lacking. Aim of this study was to determine early benefit from rt-PA in patients with aphasia.

Methods

Data of stroke patients treated by iv thrombolysis was scrutinized for the presence of aphasia defined as ≥1 point for aphasia on the National Institute of Health Stroke Scale (NIHSS). Improvement was defined as a gain of ≥1 point within 24 h. Cranial computed tomography (CT) scans were evaluated regarding early ischemic changes (EICs), infarct volume and localization.

Results

Fifty patients with aphasia were included. 16 (32%) of patients improved (4 (36%) minor, 7 (41%) moderate, 5 (23%) major stroke patients), while 44 (62%) remained unchanged. Of 28 patients with EICs, 10 (36%) improved compared to 7 out of 22 (32%) patients without (p = 0.773). Aphasia outcome was significantly associated with infarct volume at admission and at 24 h (Kruskal–Wallis, p = 0.033, p ≤ 0.001, respectively).

Conclusion

EICs are not predictive of aphasia outcome and patients with improvement showed smaller infarct volumes. One third improved within 24 h, while two thirds remained unchanged. This might justify a closer follow-up of aphasia in stroke patients at the acute stage.     

Common carotid intima media thickness as a marker of clinical severity in patients with symptomatic extracranial carotid artery stenosis

Objectives

Increased common carotid artery intima-media thickness (CCA-IMT) is a risk factor for ischemic stroke and especially large vessel atherothrombotic infarction. However, the potential association of stroke severity with the intima-media thickening has not been previously studied. We sought to investigate the association between CCA-IMT and clinical severity of ischemic stroke in patients with symptomatic extracranial carotid artery stenosis (SCAS).

Patients and methods

Consecutive patients with acute, first-ever ischemic stroke and SCAS (50%–99%) were prospectively evaluated. All subjects underwent IMT measurements at the far wall of CCA. Stroke severity was assessed using the National Institute of Health Stroke Scale (NIHSS) on hospital admission and Barthel Ambulatory Index (BI) at hospital discharge.

Results

CCA-IMT was strongly correlated to NIH (Spearman's correlation coefficient: r = 0.546, p < 0.001) and BI (r = −0.450, p < 0.001) in the study population (n = 102). A 0.1 mm increase in CCA-IMT was independently associated with increasing NIHSS-scores on hospital admission (β: 0.510; p < 0.001) and decreasing BI-scores at hospital discharge (β: −0.483; p < 0.001) even after adjustment for demographic characteristics and cardiovascular risk factors. After including baseline stroke severity (NIHSS) in the multivariate linear regressions models evaluating early functional outcome, only NIHSS was independently related to BI (standardized linear regression coefficient: −0.776, p < 0.001), while the initial association between IMT and BI did not retain its statistical significance (β: −0.074, p = 0.276).

Conclusions

Increased CCA-IMT is independently associated with more severe stroke on admission in patients with SCAS.     

Higher mean platelet volume determined shortly after the symptom onset in acute ischemic stroke patients is associated with a larger infarct volume on CT brain scans and with worse clinical outcome

Objective

Mean platelet volume (MPV) determined shortly after the onset of acute ischemic stroke represents the pre-stroke values. Data on its relationship to stroke severity/outcome have been conflicting. We related MPV to infarct volume on CT brain scans and risk of death/dependence 7 days and 3 months post-stroke.

Methods

MPV (within 30 h since stroke onset), infarct volume (13–83 h since stroke onset) and clinical outcomes were evaluated in 81 consecutive patients (32 men, age 52–91 years, 10 small artery occlusion, 10 large artery atherosclerosis, 29 cardioembolic, 32 multiple probable/possible etiology).

Results

Higher MPV was independently associated with larger ln-infarct volume [estimate 0.259, 95% confidence interval (CI) 0.004–0.513, P = 0.046], greater risk of death/dependence 7 days post-stroke [relative risk (RR) = 1.077, 95% CI 1.005–1.115, P = 0.036], and greater risk of death/dependence 3 months post-stroke (RR = 1.077, 95% CI 1.001–1.158, P = 0.048). Considered covariates: stroke etiology, CT scan timing, platelet count and other hematological parameters, demographic variables, history of cerebrovascular, cardiac or cardiovascular diseases, diabetes, serum chemistry, previous antiplatelet and statin use and treatments delivered after the index event.

Conclusions

Data support the view about MPV as a determinant of severity/outcome of the acute ischemic stroke.     

Oclusión arterial de gran vaso diagnosticada por angiografía por tomografía computarizada en el ictus isquémico agudo: frecuencia,factores predictores y seguridad

Introduction

Demonstrating artery occlusion in ischaemic stroke has gained importance due to the increasing availability of endovascular therapies. This study evaluates the frequency of artery occlusion, its associated factors, and complications following the use of CT-angiography in acute stroke.

Methods

We retrospectively analysed a cohort of patients who suffered acute ischaemic stroke between July and-December 2011.

Results

We included 157 patients (mean age, 74 ± 11; mean NIHSS score, 5 [2-13]). Of that total, 56.7% of the patients were admitted to hospital during the first 8 hours. CT-angiography was performed in 71 cases (45.2%); arterial large-vessel occlusion was detected in 37 (52.1%) of these cases, and the most frequent site was M1 (40%). Univariate analysis showed that the NIHSS score (17 vs 7, P < .001) and atrial fibrillation (64% vs 32%, P = .006) were associated with artery occlusion. A logistic regression analysis was performed subsequently, confirming these associations. There were no cases of contrast-induced nephropathy. Door-to-needle time for intravenous thrombolysis was 61.2 ± 24.5 minutes in patients who underwent CT-angiography, and 53.5 ± 34.3 minutes in those who did not (P = .495).

Conclusions

Arterial occlusions are seen in 23.6% of patients, especially in those who are admitted during the first few hours. NIHSS score serves as a useful predictive factor.     

Intravenous rt-PA in patients with ischaemic stroke and renal dysfunction

Objective

Renal dysfunction (RD) increases risk for ischaemic stroke (IS). The impact of RD on the effects of iv-thrombolysis in the Caucasian population has not been fully determined.

Aims

To evaluate the associations between RD and the outcome of iv-thrombolysis in Caucasian patients with IS.

Methods

The observational, multicentre study included 404 patients with IS who were treated with iv-thrombolysis. RD was defined as estimated glomerular filtration rate ≤60 ml/min/1.73 m². Outcome was assessed with modified Rankin Score at 3 months after the stroke onset.

Results

Medians baseline NIHSS score did not differ between groups of patients with and without RD (12.0 vs. 11.0 pts, p = 0.33). Unfavourable outcome was found in 52.1% of patients with and in 41.2% of patients without RD (p = 0.05), mortality was higher in patients with RD (29.9% vs. 14.3%, p < 0.001), and the presence of haemorrhagic transformation (HT) did not differ between the groups (17.1% vs. 17.1% respectively, p = 0.996). A multivariate analysis showed no impact of RD on the unfavourable outcome (OR 0.98; 95%CI 0.88–1.10), mortality (OR 0.92; 95%CI 0.81–1.05) or presence of HT (OR 1.03; 95%CI 0.90–1.18).

Conclusions

We found no impact of RD on the safety and efficacy of iv-thrombolysis in Caucasian patients with IS.     

Prehospital transfer medicalization increases thrombolysis rate in acute ischemic stroke. A French stroke unit experience

Objectives

Narrow therapeutic window is a major cause of thrombolysis exclusion in acute ischemic stroke. Whether prehospital medicalization increases t-PA treatment rate is investigated in the present study.

Patients and methods

Intrahospital processing times and t-PA treatment were analyzed in stroke patients calling within 6 h and admitted in our stoke unit. Patients transferred by our mobile medical team (SAMU) and by Fire Department (FD) paramedics were compared.

Results

193 (61.6%) SAMU patients and 120 (38.4%) FD patients were included within 30 months. Clinical characteristics and onset-to-call intervals were similar in the two groups. Mean door-to-imaging delay was deeply reduced in the SAMU group (52 vs. 159 min, p < 0.0001) and was <25 min in 50% of SAMU patients and 14% of FD patients (p < 0.0001). SAMU management was the only independent factor of early imaging (p = 0.0006). t-PA administration rate was higher in SAMU group than in FD group (42% vs. 28%, p = 0.04). Proportion of patients with delayed therapeutic window was higher in FD group than in SAMU group (38% vs. 26%, p < 0.0001).

Conclusion

Prehospital transfer medicalization promotes emergency room bypass, direct radiology room admission and high thrombolysis rate in acute ischemic stroke.     

Less favorable neurological recovery after acute stroke in patients with hypercholesterolemia

Objectives

We aimed to investigate the effect of hypercholesterolemia on recovery after acute ischemic stroke.

Methods

Data of 3048 patients admitted for acute ischemic stroke from January to December 2009 were collected from the Stroke Registry in the Chang Gung Healthcare System. Baseline characteristics of patients with and without hypercholesterolemia were compared. The association of hypercholesterolemia with neurological severity and recovery was analyzed using multivariate logistic regression. The patients were then divided on the basis of age for subgroup analysis.

Results

The number of patients with and without a history of hypercholesterolemia was 474 (15.6%) and 2574 (84.4%), respectively. Univariate analysis showed that patients with hypercholesterolemia had a lower National Institutes of Health Stroke Scale (NIHSS) score on admission (p = 0.004). However, during hospitalization, these patients displayed less improvement in their NIHSS score (p = 0.002). These results remained significant in multivariate logistic regression analysis (p < 0.001 and p = 0.002, respectively). Subgroup analysis showed a similar association for hypercholesterolemia in both younger (age < 70) and older (age ≥ 70) age groups.

Conclusions

Acute ischemic stroke in patients with hypercholesterolemia was correlated with reduced severity on admission and less favorable recovery during hospitalization, regardless of age.     

New cerebral microbleeds in ischemic stroke patients on warfarin treatment: Two-year follow-up

Objective

Cerebral microbleeds (CMBs) are known to be indicative of bleeding-prone microangiopathy. Little is known about the significance of CMBs in anticoagulated patients. We determined the frequency of new CMBs in ischemic stroke patients who had been receiving warfarin treatment for 2 years.

Methods

A total of 204 ischemic stroke patients on warfarin therapy for 2 years underwent a repeat MRI. We compared demographic features, vascular risk factors, and radiological findings of patients with and without new CMBs.

Results

New CMBs on gradient-echo MRI were found in 29 of 204 patients (10%). Of 35 patients who had CMBs in the original study, 9 developed new CMBs after 2 years (26%), compared with 20 of the 169 patients (12%) who did not have CMBs at baseline (p = 0.03). Patients with new CMBs were older than patients without CMBs (p = 0.04), and the frequency of leukoaraiosis was significantly higher (p = 0.02). The mean duration of warfarin treatment was not significantly different between the patients with and without new CMBs (p = 0.28).

Conclusion

This longitudinal study suggested that the presence of CMBs at baseline increased the frequency of new CMBs in patients on warfarin therapy.     

Stem cell therapy: A clinical trial of stroke

Background

The alarming disability burden and a high prevalence rate of stroke in India has encouraged the researchers to develop regenerative therapies to reduce clinical deficits. This study evaluates safety, feasibility and efficacy of autologous mononuclear and mesenchymal cell transplantation in stroke patients evaluated on clinical scores and functional imaging (fMRI and DTI).

Methods

Forty (n = 40) stroke patients were recruited with the inclusion criteria as: 3 months to 2 years of index event, power of hand muscles of at least 2; Brunnstrom stage: 2–5; conscious and comprehendible. Fugl Meyer (FM), modified Barthel Index (mBI), Medical Research Council (MRC) grade for strength, Ashworth tone scale and functional imaging was used for assessments at baseline, 8 weeks and 24 weeks. 50–60 million cells in 250 ml saline were infused intravenously over 2–3 h.

Results

The safety test profile was normal with no mortality or cell related adverse reactions in stem cell patients. Among outcome parameters, only modified Barthel Index (mBI) showed statistical significant improvement (p < 0.05) in the stem cell group. An increased number of cluster activation in Brodmann areas BA 4, BA 6 was observed post stem cell infusion indicating neural plasticity.

Conclusion

Autologous intravenous stem cell therapy is safe and feasible. Stem cells act as “scaffolds” for neural transplantation and may aid in repair mechanisms in stroke.