Catastrophic Multiple Microbleeds Caused by Infective Endocarditis Following Intravenous Thrombolysis and Endovascular Thrombectomy

Ischemic stroke is one of the most common complications of infective endocarditis (IE). IE must be considered as one of the causes of acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO), but early diagnosis of IE is difficult. AIS with ELVO must be treated using endovascular thrombectomy (EVT), with or without intravenous thrombolysis (IVT). IVT for AIS due to IE is not well established and remains controversial because of the risk of intracranial hemorrhage. A 42-year-old man suffered from right hemiparesis and disorientation, and AIS with ELVO was diagnosed. EVT with IVT was successfully performed and recanalization was achieved, but catastrophic multiple cerebral microbleeds appeared after treatment. EVT without IVT could be chosen for AIS caused by IE to avoid hemorrhagic complications. Hypointense signal spots on T2*-weighted magnetic resonance imaging (MRI) and susceptibility-weighted MRI could facilitate early diagnosis of IE.     

Temporal Trends in the Use of Acute Recanalization Therapies for Ischemic Stroke in Patients with Cancer

Objective: We sought to characterize the US nationwide temporal trends in recanalization therapy utilization for ischemic stroke among patients with and without cancer. Methods: We identified all acute ischemic stroke (AIS) hospitalizations in the National Inpatient Sample from January 1, 1998 to September 30, 2015. The primary exposure was solid or hematologic cancer. The primary outcome was use of intravenous thrombolysis. The secondary outcome was use of endovascular therapy (EVT). Results: Among 9,508,804 AIS hospitalizations, 503,510 (5.3%) involved cancer patients. Intravenous thrombolysis use among ischemic stroke patients with cancer increased from .01% (95% confidence interval [CI], .00%-.02%) in 1998 to 4.91% (95% CI, 4.33%-5.48%) in 2015, whereas intravenous thrombolysis use among ischemic stroke patients without cancer increased from .02% (95% CI, .01%-.02%) in 1998 to 7.22% (95% CI, 6.98%-7.45%) in 2015. The demographic- and comorbidity-adjusted odds ratio/year of receiving intravenous thrombolysis was similar in patients with cancer (1.21; 95% CI, 1.20-1.23) versus those without (1.20; 95% CI, 1.19-1.21). EVT use among ischemic stroke patients with cancer increased from .05% (95% CI, .02%-.07%) in 2006 to 1.90% (95% CI, 1.49%-2.31%) in 2015, whereas EVT use among ischemic stroke patients without cancer increased from .09% (95% CI, .00%-.18%) in 2006 to 1.88% (95% CI, 1.68%-2.09%) in 2015. Conclusions: Among 9.5 million AIS hospitalizations, patients with cancer received intravenous thrombolysis about two thirds as often as patients without cancer. This difference persisted over time despite increased utilization in both groups. EVT utilization was similar between cancer and non–cancer AIS patients.     

大面积梗死急性缺血性卒中患者血管内治疗的有效性和安全性研究

目的 观察低ASPECTS评分的大面积梗死患者血管内治疗的有效性和安全性,并探讨预后的影响 因素。 方法 从急性缺血性卒中血管内治疗关键技术及急救流程改进研究-前瞻性、多中心、登记研究 （endovascular treatment key technique and emergency work flow improvement of acute ischemic stroke, ANGEL-ACT）中筛选接受血管内治疗,且ASPECTS/后循环ASPECTS（post-circulation ASPECTS,pc- ASPECTS）＜6分的大面积脑梗死患者,分析影响患者预后的因素。有效性终点为术后90 d预后良好 （mRS 0～3分）,安全性终点包括术后24 h内症状性颅内出血（symptomatic intracranial hemorrhage,sICH） 和术后90 d全因死亡。 结果 共纳入121例患者,其中男性89例（73.55%）,中位年龄62.0（54.0～72.0）岁,失访6例,纳 入统计分析的共115例患者。术后90 d预后良好53例（46.09%）,基线低NIHSS（OR 0.908,95%CI 0.841～0.980,P =0.0130）和闭塞血管再通成功（OR 13.676,95%CI 1.396～134.004,P =0.0247）是术 后90 d预后良好的独立预测因子。术后24 h内发生sICH 21例（18.26%）,穿刺至再通时间长（OR 1.009, 95%CI 1.002～1.017,P =0.0163）和病变血管合并串联狭窄（OR 4.202,95%CI 1.457～12.119,P =0.0079） 是术后24 h内sICH的独立预测因子。术后90 d全因死亡23例（20.00%）,基线高NIHSS（OR 1.089, 95%CI 1.014～1.170,P =0.0186）和术后24 h内sICH（OR 4.688,95%CI 1.382～15.898,P =0.0132）是术 后90 d全因死亡的独立预测因子。 结论 大面积梗死的急性缺血性卒中患者接受血管内治疗虽然风险较高,但术前严格地筛选低 NIHSS患者,术中尽量获得闭塞血管再通成功能够使患者获益。     

Safety and Efficacy of Reperfusion Therapies for Acute Ischemic Stroke Patients with Active Malignancy

Background and Purpose: Epidemiological correlations between active malignancy (AM) and acute ischemic stroke (AIS) are well-established. However, the effect of reperfusion strategies, particularly mechanical thrombectomy (MT), has been barely investigated in patients with AIS and AM. We aim to evaluate safety and efficacy of reperfusion strategies in such patients. Materials and Methods: We performed a case-control analysis comparing patients with AM and AIS (AM group) to a group of cancer-free patients with AIS (control group). All enrolled patients underwent reperfusion therapies (i.e. intravenous thrombolysis, MT, intravenous thrombolysis plus MT). Main outcomes were 3-month functional independence, successful reperfusion, 3-month mortality, symptomatic intracranial hemorrhage. Results: Total 24 patients with AM and AIS (mean age: 69 ± 10.1) were individually matched to 24 control patients (mean age: 70.7 ± 9.3). In both groups 50% were treated with MT, 46% with intravenous thrombolysis and 4% with intravenous thrombolysis plus MT. No difference were found in successful reperfusion, 3-month functional independence, symptomatic intracranial hemorrhage, and mortality. However an overall mortality of 33% in the AM group was reported. Conclusions: Reperfusion strategies for AIS patients with AM seem to be safe and effective. However an individualized approach to understand cancer stage and life-expectation is warranted.     

Is off-label thrombolysis safe and effective in a real-life primary stroke center? A retrospective analysis of data from a 5-year prospective database

BackgroundIntravenous thrombolysis (IVT) use for acute ischemic stroke (AIS) varies among countries, partly due to guidelines and product labeling changes. The study aim was to identify the characteristics of patients with AIS treated with off-label IVT and to determine its safety when performed in a primary stroke center (PSC).MethodsThis observational, single-center study included all consecutive patients admitted to Perpignan PSC for AIS and treated with IVT and patients transferred for EVT, between January 1, 2015 and December 31, 2019. Data of patients treated with IVT according to (“in-label group”) or outside (“off-label”) the initial guidelines and manufacturer's product specification were compared. Safety was assessed using symptomatic intracerebral hemorrhage (SIH) as the main adverse event.ResultsAmong the 892 patients in the database (834 screened by MRI, 93.5%), 746 were treated by IVT: 185 (24.8%) “in-label” and 561 (75.2%) “off-label”. In the “off-label” group, 316 (42.4% of the cohort) had a single criterion for “off-label” use, 197 (26.4%) had two, and 48 (6.4%) had three or more criteria, without any difference in IVT safety pattern among them. SIH rates were comparable between the “off-label” and “in-label” groups (2.7% vs. 1.1%, P = 0.21); early neurological deterioration and systematic adverse event due to IVT treatment were similar in the 2 groups. “Off-label” patients had higher in-hospital (8.7% vs. 3.8%, P = 0.05) and 3-month mortality rates (12.1% vs 5.4%, P < 0.01), but this is explained by confounding factors as they were older (76 vs 67 years, P < 0.0001) and more dependent (median modified Rankin scale score 0.4 vs 0.1, P < 0.0001) at admission.Conclusions“Off-label” thrombolysis for AIS seems to be safe and effective in the routine setting of a primary stroke center.     

急性后循环大血管闭塞桥接治疗与直接取栓结局及相关因素研究：一项多中心前瞻性队列研究

目的 比较发病4.5 h内的急性后循环大血管闭塞患者静脉溶栓（intravenous thrombolysis，IVT）联合 血管内治疗（endovascular treatment，EVT）与直接取栓治疗的疗效差异。 方法 本研究为多中心前瞻性队列研究，连续纳入2018年7月-2019年5月全国18家分中心发病4.5 h 内的急性后循环大血管闭塞患者。根据实际治疗方式，分为桥接治疗组（IVT+EVT）和直接取栓组 （direct endovascular treatment，D-EVT）。主要结局为发病90 d的神经功能预后，良好预后定义为mRS评 分0～2分，采用多因素Logi sti c回归分析评估两组90 d预后的差异。 结果 研究纳入123例患者，平均年龄62.79±11.07岁，男性85例（69.11%），其中D -EVT组98例 （79.67%），IVT+EVT组25例（20.33%）。与IVT+EVT组相比，D-EVT组取栓≥3次病例更多（26.52% vs 8.00%，P =0.04）；多因素分析显示，IVT+EVT组良好预后比例高于D -EVT组（aOR 0.2，95%CI 0.06～0.71，P =0.01）。 结论 对于发病4.5 h内的急性后循环大血管闭塞患者，静脉溶栓联合血管内治疗较单纯血管内治 疗90 d神经功能预后更佳。     

Relevance of National Institutes of Health Stroke Scale subitems for best revascularization therapy in minor stroke patients with large vessel occlusion: An observational multicentric study

Background and purpose

The best management of acute ischemic stroke patients with a minor stroke and large vessel occlusion is still uncertain. Specific clinical and radiological data may help to select patients who would benefit from endovascular therapy (EVT). We aimed to evaluate the relevance of National Institutes of Health Stroke Scale (NIHSS) subitems for predicting the potential benefit of providing EVT after intravenous thrombolysis (IVT; “bridging treatment”) versus IVT alone.

Methods

We extracted demographic, clinical, risk factor, radiological, revascularization and outcome data of consecutive patients with M1 or proximal M2 middle cerebral artery occlusion and admission NIHSS scores of 0–5 points, treated with IVT ± EVT between May 2005 and March 2021, from nine prospectively constructed stroke registries at seven French and two Swiss comprehensive stroke centers. Adjusted interaction analyses were performed between admission NIHSS subitems and revascularization modality for two primary outcomes at 3 months: non-excellent functional outcome (modified Rankin Scale score 2–6) and difference in NIHSS score between 3 months and admission.

Results

Of the 533 patients included (median age 68.2 years, 46% women, median admission NIHSS score 3), 136 (25.5%) initially received bridging therapy and 397 (74.5%) received IVT alone. Adjusted interaction analysis revealed that only facial palsy on admission was more frequently associated with excellent outcome in patients treated by IVT alone versus bridging therapy (odds ratio 0.47, 95% confidence interval 0.24–0.91; p = 0.013). Regarding NIHSS difference at 3 months, no single NIHSS subitem interacted with type of revascularization.

Conclusions

This retrospective multicenter analysis found that NIHSS subitems at admission had little value in predicting patients who might benefit from bridging therapy as opposed to IVT alone. Further research is needed to identify better markers for selecting EVT responders with minor strokes.     

Reperfusion strategies in stroke due to isolated cervical internal carotid artery occlusion: systematic review and treatment comparison

Neurological Sciences - Despite intravenous thrombolysis (IVT) and endovascular treatment (EVT) have been demonstrated effective in acute ischemic stroke (AIS) due to large vessel occlusions, there...     

房颤对急性缺血性脑卒中患者尿激酶溶栓疗效的影响

目的 探讨房颤是否对急性缺血性脑卒中患者尿激酶溶栓疗效产生影响及对于合并房颤的急性缺血性脑卒中患者是否给予尿激酶溶栓治疗.方法 本研究为回顾性病例对照研究.从2006年4月到2012年1月连续收集发病6小时内给予尿激酶溶栓的急性缺血性脑卒中患者作为研究对象.根据有无合并房颤将符合入选标准的病例分为两组:房颤组(26例)和无房颤组(60例).采用美国国立卫生研究院卒中量表(NIHSS)、改良的Rankin量表评价治疗效果.结果 房颤组与无房颤组溶栓治疗后7d溶栓有效率比较,差异无统计学意义(57.7％ vs 56.7％,P＞0.05).在尿激酶静脉溶栓治疗后90 d,房颤组57.7％的病人功能恢复好,无房颤组65.0％的病人功能恢复好,两组比较差异无统计学意义(P＞0.05).房颤组颅内出血的发生率、症状性颅内出血的发生率及死亡率均较高,但与无房颤组比较差异均无统计学意义.结论 合并房颤的急性缺血性脑卒中患者与无合并房颤的急性缺血性脑卒中患者均可以从溶栓中获益,房颤对急性缺血性脑卒中患者尿激酶溶栓疗效无显著影响,合并房颤的急性缺血性脑卒中患者应予尿激酶溶栓治疗.     

后循环急性缺血性卒中血管内治疗与静脉溶栓的对照研究

目的 比较后循环大血管闭塞致急性缺血性卒中患者接受血管内治疗（endovascular treatment，EVT） 与单纯静脉溶栓（intravenous thrombolysis，IVT）治疗后的临床结局。 方法 纳入2012年3月-2016年11月期间在北京天坛医院行EVT与IVT治疗的后循环大血管闭塞所致 急性缺血性卒中患者，以1∶1比例匹配两组的年龄、性别、基线NIHSS评分、发病至治疗时间及卒中亚型 （TOAST分型），匹配患者的NIHSS评分≥10分。主要疗效结局为治疗后90 d的mRS评分，安全性结局为 24 h ICH及90 d全因死亡率。 结果 共纳入328例后循环急性缺血性卒中患者，其中EVT组69例，IVT组259例，匹配后两组基线数 据相似，每组各55例。各卒中亚型比例在两组均有显著性差异（所有P <0.001），两组均以大动脉粥 样硬化型为主，其中EVT组63例（91.3%），IVT组164例（63.3%）。临床疗效结局显示匹配后EVT组90 d mRS评分≤1分比例（30.9% vs 38.2%，校正OR 0.724，95%CI 0.329～1.595，P =0.423）及mRS评分≤2 分比例（38.2% vs 50.9%，校正OR 0.596，95%CI 0.279～1.272，P =0.181）均低于IVT组，但差异均无统 计学意义。安全性结局方面，24 h症状性脑出血及治疗后90 d全因死亡率，两组比较差异也无统计学 意义。 结论 对于后循环大血管闭塞所致急性缺血性卒中患者行EVT治疗和单纯IVT治疗，在疗效及安全 性结局方面均无显著性差异。     

Endovascular therapy for acute ischemic stroke: The importance of blood pressure control,sedation modality and anti-thrombotic management to improve functional outcomes

Since 2015, endovascular therapy (EVT) following intravenous thrombolysis (IVT) is the gold standard treatment for patients suffering from acute ischemic stroke (AIS) due to an anterior large vessel occlusion (LVO). Despite high recanalization rates, nearly half of successfully treated patients remain dependent at three months. This result underlines that other factors may have a prognostic value, such as blood pressure (BP) management, the sedation modality and anti-thrombotic strategy during and after EVT. Extreme BP variations before and after recanalization are associated with worse outcomes. During EVT, BP variability is strongly associated with worse functional outcomes. Indeed, several studies have highlighted the deleterious impact of BP drops and hypotension duration on functional outcomes and final infarct volume. Interestingly, several studies have shed light on the potential value of an individualized BP management based on several baseline clinical or radiological parameters, such as the collateral status or the circle of Willis conformation. Such approaches are being investigated and could lead to a paradigm shift compared to the one-size-fits-all approach. After EVT, recent evidence suggests that an intensive systolic BP reduction (100–129 mmHg) does not reduce the occurrence of intracranial hemorrhage compared to the guideline-recommended systolic BP control (130–185 mmHg). Anesthetic management also seems to have a major impact on functional outcome. The latest studies suggest that general anesthesia may be associated with better functional outcomes and faster procedures and may have neuroprotective effects. However, further studies are needed in order to clarify the best anesthetic management for EVT. Finally, new anti-thrombotic treatments are increasingly used during EVT and are currently investigated to increase recanalization rates and improve reperfusion. However, the current literature is scarce regarding the association of IVT, EVT and antiplatelet therapy such as anti-GPIIbIIIa or P2Y12 inhibitors. These strategies raise several issues, such as an increase in intracranial hemorrhage rates.     

急性后循环大血管闭塞桥接治疗与直接取栓结局及相关因素研究：一项多中心前瞻性队列研究

目的 比较发病4.5 h内的急性后循环大血管闭塞患者静脉溶栓（intravenous thrombolysis，IVT）联合
血管内治疗（endovascular treatment，EVT）与直接取栓治疗的疗效差异。
方法 本研究为多中心前瞻性队列研究，连续纳入2018年7月-2019年5月全国18家分中心发病4.5 h
内的急性后循环大血管闭塞患者。根据实际治疗方式，分为桥接治疗组（IVT+EVT）和直接取栓组
（direct endovascular treatment，D-EVT）。主要结局为发病90 d的神经功能预后，良好预后定义为mRS评
分0～2分，采用多因素Logi sti c回归分析评估两组90 d预后的差异。
结果 研究纳入123例患者，平均年龄62.79±11.07岁，男性85例（69.11%），其中D -EVT组98例
（79.67%），IVT+EVT组25例（20.33%）。与IVT+EVT组相比，D-EVT组取栓≥3次病例更多（26.52%
vs 8.00%，P =0.04）；多因素分析显示，IVT+EVT组良好预后比例高于D -EVT组（aOR 0.2，95%CI
0.06～0.71，P =0.01）。
结论 对于发病4.5 h内的急性后循环大血管闭塞患者，静脉溶栓联合血管内治疗较单纯血管内治
疗90 d神经功能预后更佳。     

Case Fatality Decline from 2009 to 2013 among Medicare Beneficiaries with Ischemic Stroke

ObjectivesThis study aimed to examine the temporal trend of 30-day and 1-year mortality among U.S. Medicare beneficiaries who were hospitalized for ischemic stroke, with special focus on the mortality among subgroup of patients in relation to acute reperfusion therapies including intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT).MethodsWe evaluated Medicare fee-for-service beneficiaries age 65 years or older who were hospitalized for ischemic stroke between 2009 and 2013. Multivariable Cox proportional hazards models were generated to analyze the trend of adjusted mortality.ResultsA total of 1,070,574 patients were included in the study. The 30-day mortality did not change among patients who were not treated with IVT or EVT. It decreased by 13% among patients treated with IVT but not EVT (HR = .87, 95% CI .82-.92), 25% among patients treated with EVT but not IVT (HR = .75, 95% CI .59-.95), and 37% among patients treated with both IVT and EVT (HR = .63, 95% CI .52-.77). One-year mortality decreased by 19% among patients who were not treated with IVT nor EVT (HR = .81, 95% CI .80-.83), 22% among those treated with IVT but not EVT (HR = .78, 95% CI .75-.81), 33% among those treated with EVT but not IVT (HR = .67, 95% CI .55-.81), and 38% among those treated with both IVT and EVT (HR = .62, 95% CI .53-.73).ConclusionsFrom 2009 to 2013, the 30-day stroke case fatality decreased only among the patients received reperfusion therapy. The 1-year mortality declined among all the stroke patients, with the greatest decline among those treated with both IVT and EVT.     

Mechanical Recanalization after Transfer from a Distant Primary Stroke Center: Effectiveness and Future Directions

Introduction: Little is known about the effectiveness of endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) admitted to a primary stroke center (PSC). The aim of this study was to assess EVT effectiveness after transfer from a PSC to a distant (156 km apart; 1.5 hour by car) comprehensive stroke center (CSC), and to discuss perspectives to improve access to EVT, if indicated. Patients and Method: Analysis of the data collected in a 6-year prospective registry of patients admitted to a PSC for AIS due to LVO and selected for transfer to a distant CSC for EVT. The rate of transfer, futile transfer, EVT, reperfusion (thrombolysis in cerebral infarction score ≥2b-3), and relevant time measures were determined. Results: Among the 529 patients eligible, 278 (52.6%) were transferred and 153 received EVT (55% of transferred patients) followed by reperfusion in 115 (overall reperfusion rate: 21.7%). Median times (interquartile range) were: 90 minutes (76-110) for PSC-door-in to PSC-door-out, 88 minutes (65-104) for PSC-door-out to CSC-door-in, 262 minutes (239-316) for PSC-imaging to reperfusion, and 393 minutes (332-454) for symptom onset to reperfusion. At 3 months, rates of favorable outcome (modified Rankin Scale 0-2) were not significantly different between patients eligible for EVT (42.4%), transferred patients (49.1%) and patients who underwent EVT (34.1%). Discussion and Conclusions: Our study suggests that transfer to a distant CSC is associated with reduced access to early EVT. These results argue in favor of on-site EVT at high volume PSCs that are distant from the CSC.     

Safety of Mechanical Thrombectomy with Combined Intravenous Thrombolysis in Stroke Treatment 4.5 to 9 Hours from Symptom Onset

BackgroundAn extended time window for intravenous thrombolysis (IVT) for acute stroke patients up to 9 hours from symptom onset has been established in recent trials, excluding patients who received mechanical thrombectomy (MT). We therefore investigated whether combined therapy with IVT and MT (IVT+MT) is safe in patients with ischemic stroke and large vessel occlusion (LVO) in an extended time window.MethodsWe retrospectively analyzed patients with anterior circulation ischemic stroke and LVO who were treated within 4.5 to 9 hours after symptom onset using MT with or without IVT. Primary endpoint was the occurrence of any intracranial hemorrhage (ICH). Multivariable logistic regression was used to adjust for potential confounders.ResultsIn total, 168 patients were included in the study, 44 (26%) were treated with IVT+ MT. 133 (79%) patients had a M1-/distal carotid artery occlusion. Median ASPECT-Score was 8 (IQR 7-10) and complete reperfusion (mTICI 2b-3) was achieved in 132 (79%) patients. 18 (41%) of the patients in the IVT+MT group developed any ICH vs. 45 (36%) patients in the direct MT group (p=0.587). Symptomatic ICH occurred in 5 (11%) patients with IVT+MT vs. 8 (6%) patients receiving direct MT (p=0.295). In multivariable analysis, IVT+MT was not an independent predictor of ICH (adjusted for NIHSS, degree of reperfusion, symptom-onset-to-treatment time and therapy with tirofiban; OR 0.95 [95% CI 0.43-2.08], p=0.896).ConclusionMechanical thrombectomy in stroke patients seems to be safe with combined intravenous thrombolysis within 4.5 to 9 hours after onset as it did not significantly increase the risk for intracranial hemorrhage.     

Endovascular thrombectomy with or without intravenous thrombolysis in acute basilar artery occlusion ischemic stroke: A meta-analysis

IntroductionIt is poorly understood if endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) better facilitates clinical outcomes in patients with acute basilar artery occlusion (BAO) ischemic stroke.MethodsA systematic literature review and meta-analysis was completed to investigate the outcomes of EVT with IVT versus direct EVT alone in acute BAO. Data was collected from the literature and pooled with the authors’ institutional experience. The primary outcome measure was 90-day modified Rankin sale (mRS) of 0-2. Secondary measures were successful post-thrombectomy recanalization defined as mTICI ≥2b, 90-day mortality, and rate of symptomatic ICH.ResultsOur institutional experience combined with three multicenter studies resulted in a total of 1,127 patients included in the meta-analysis. 756 patients underwent EVT alone, while 371 were treated with EVT+IVT. Patients receiving EVT+IVT had a higher odds of achieving a 90-day mRS of ≤ 2 compared to EVT alone (OR: 1.50, 95% CI 1.15 to 1.95, P =0.002, I² =0%). EVT+IVT also had a lower odds of 90-day mortality (OR: 0.57, 95% CI 0.37 to 0.89, P=0.01, I²=24%). There was no difference in sICH between the two groups (OR: 1.0, 95% CI: 0.56 to 1.79, P=0.99, I²=0%). There was also no difference in post-thrombectomy recanalization rates defined as mTICI ≥2b (OR: 1.11, 95% CI 0.70 to 1.75, P = 0.65, I²=37%).ConclusionsOn meta-analysis, EVT with bridging IVT results in superior 90-day functional outcomes and lower 90-day mortality without increase in symptomatic ICH. These findings likely deserve further validation in a randomized controlled setting.     

Renal Dysfunction Associated with Symptomatic Intracranial Hemorrhage after Intravenous Thrombolysis

Background and Aim: Renal dysfunction (RD) is prevalent in patients with acute ischemic stroke requiring intravenous thrombolysis. The relationship between renal function and thrombolysis related intracranial hemorrhagic (ICH) complications is contradictory according to previous studies. The current study is to clarify whether RD could increase the risk of symptomatic intracranial hemorrhage (SICH) after recombinant tissue plasminogen activator (IV rtPA) in acute ischemic stroke patients. Methods: In this observational study, acute ischemic stroke patients who received IV rtPA within 4.5 hours of symptom onset were retrospectively analyzed. Creatinine levels on admission served to calculate glomerular filtration rate (GFR) to estimate RD. SICH was defined with National Institute of Neurological Disorder and Stroke (NINDS, SICH_NINDS) or European Cooperative Acute Stroke Study II (ECASS II, SICH_ECASSII) criteria. Association of RD with SICH was assessed using continuous GFR or binary GFR (RD defined as GFR < 90 ml/minute/1.73 m²). Results: Of 312 patients included, the incidence of SICH_NINDS was 7.69%, of SICH_ECASSII was 5.45%. Patients with RD had higher prevalence of SICH_NINDS (12.80% versus 2.03%, P < .001) and SICH_{ECASS II} (9.15% versus 1.35%, P = .002)_. GFR as a continuous variable was associated with SICH_NINDS (OR_adjust = .97, P = .003), but not with SICH_{ECASS II}. GFR less than 90 ml/minute/1.73 m² remained independently associated with SICH_NINDS (OR_adjust = 4.79, P = .016), and SICH_{ECASS II} (OR_adjust = 2.99, P = .032) in multiple logistic regression analysis. Conclusions: Renal function is independently associated with SICH after IV rtPA thrombolysis. RD is an independent predictor for both SICH_NINDS and SICHE_{CASS II}. RD should be considered when evaluating the risk of intravenous thrombolysis with IV rtPA.     

A new clinical score to predict the possibility of stroke patients receiving intravenous thrombolysis

BackgroundWe aimed to develop and validate a clinical score to identify the factors which contribute to variation in, and influence clinician's decision-making about treating acute ischemic stroke (AIS) patients with Intravenous thrombolysis (IVT).MethodsWe retrospectively included consecutive AIS patients within 4.5 hours after onset in the emergency department (ED), who were admitted to a comprehensive stroke center in Jiangsu province, China. The patients were randomly divided into derivation (60%) and validation data sets (40%) to develop and validate the clinical score. Multivariable stepwise forward logistic regression was performed to identify the independent predictors of IVT offering in the derivation data.ResultsOut of 526 included patients, 418 patients received thrombolytic therapy. Nine patient factors were associated with the likelihood of thrombolysis (age, time to hospital, National Institute of Health stroke scale (NIHSS) score, great vessel, facial paralysis, dizziness, headache, history of stroke, and neutrophil ratio). The c-statistics of the Intravenous Thrombolysis Score in the derivation cohort (n= 316) and validation cohort(n = 210) were 0.795 and 0.751, respectively. The performance of the scoring model was validated with a calibration plot showing good predictive accuracy for the scores in the derivation data (calibrated P = 0.861) and validation data (calibrated P = 0.876).ConclusionsThe Intravenous Thrombolysis Score for predicting the possibility of offering IVT to AIS patients indicates that clinicians differ in their thresholds for the treatment across a number of patient-related factors, which will be linked to training professional development programmes and address the impact of non-medical influences on decision-making using evidence-based strategies.     

The impact of cerebral microbleeds on intracerebral hemorrhage and poor functional outcome of acute ischemic stroke patients treated with intravenous thrombolysis: a systematic review and meta-analysis

It is still controversial whether pre-existing cerebral microbleeds (CMBs) increase the risks of intracranial hemorrhage (ICH) and poor functional outcome (PFO) in acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT). Therefore, we performed a systematic review and meta-analysis to determine the impact of CMBs on ICH and PFO of AIS patients with IVT. We searched PubMed, EMBASE and Web of Science from inception to August 3, 2016, with language restriction in English. We included studies that reported the relationship between CMBs and ICH or PFO after thrombolysis. Two retrospective and nine prospective studies met inclusion criteria (total 2702 patients). The overall prevalence of CMBs on pre-IVT MRI scans was 24.0%. Pre-existing CMBs on MRI scans were not significantly associated with a higher risk of early sICH (OR 1.74; 95% CI 0.91–3.33; I ² = 44.5%). Subgroup analyses did not substantially influence these associations. The presence of CMBs was associated with the increased risk of 3-month PFO (OR 1.58; 95% CI 1.08–2.31; I ² = 54.2%), PH (OR 2.14; 95% CI 1.34–3.42; I ² = 11.0%) and any ICH (OR 1.42; 95% CI 1.04–1.95; I ² = 0.0%), respectively. This meta-analysis showed that CMBs presence was not significantly associated with the increased risk of early sICH after IVT. However, the results also demonstrated that CMBs presence increased the risks of 3-month PFO, PH and any ICH after IVT. Due to a small number of included studies and methodological limitations, the results of this meta-analysis should be interpreted cautiously. CMBs presence should not be a contraindication to IVT for AIS patients based on the existing evidence.     

Prognostic Value of Clot Burden Score in Acute Ischemic Stroke after Reperfusion Therapies: A Systematic Review and Meta-Analysis

Background and Aim: Clot burden score (CBS) was designed to weight the thrombus status in cerebral anterior circulation. We performed a systematic review and meta-analysis to investigate the prognostic value of CBS in acute ischemic stroke (AIS) patients undergoing reperfusion therapies. Methods: We searched relevant databases for eligible articles reporting CBS in AIS patients. The effect sizes of good functional outcome, recanalization, or hemorrhagic transformation (HT) were pooled with random-/fixed-effect models. Sensitivity analyses and heterogeneity tests were performed. Results: Fifteen eligible studies enrolling 3302 AIS patients undergoing reperfusion therapies were included. AIS patients with per 1-point increase CBS were associated with good functional outcome (pooled odds ratio [OR]: 1.15, 95% confidence interval [CI]: 1.09-1.20) and high rate of recanalization (pooled OR: 1.27, 95% CI: 1.14-1.40). Results from categorical groups indicated high CBS at baseline was associated with higher likelihood of good functional outcome (pooled OR: 1.59, 95% CI: 1.30-1.94) and superior recanalization rates (pooled OR: 2.53, 95% CI: 1.79-3.57). Further stratified analyses showed in intravenous thrombolysis (IVT) alone group, increasing CBS was associated with good functional outcome (continuous pooled OR: 1.18, 95% CI: 1.10-1.27; categorical pooled OR: 3.38, 95% CI: 2.01-5.69) or recanalization (categorical pooled OR: 4.13, 95% CI: 2.00-8.51), but not in endovascular therapy alone group. No significant association was found between CBS and HT. Conclusions: CBS could be a predictor for AIS after reperfusion therapies in functional outcome and successful recanalization particularly in patients receiving IVT alone; while CBS might not be a predictor for HT.