Prior use of statins and outcome in patients with intracerebral haemorrhage

Background:  Pre-treatment with cholesterol lowering drugs of the statin family may exert protective effects in patients with ischaemic stroke and subarachnoid haemorrhage but their effects are not clear in patients with intracerebral haemorrhage (ICH).
Methods:  We recruited patients admitted to our University Hospital with an acute ICH and analysed pre-admission demographic variables, pre-morbid therapy, clinical and radiological prognostic markers and outcome variables including 90-day modified Rankin score and NIH stroke scale score (NIHSS).
Results:  We recruited 399 patients with ICH of which 101 (25%) were using statins. Statin users more often had vascular risk factors, had significantly lower haematoma volumes ( P  = 0.04) and had lower mortality rates compared with non-users (45.6% vs. 56.1%; P  = 0.11). However, statin treatment did not have a statistically significant impact on mortality or functional outcome on multiple logistic regression analysis.
Conclusions:  Treatment with statins prior to ICH failed to show a significant impact on outcome in this analysis despite lower haematoma volumes.     

High prevalence of unrecognized cerebral infarcts in first-ever stroke patients with cardioembolic sources

Background:  With magnetic resonance imaging (MRI) analysis, we investigated the prevalence, clinical significance, and factors related to the presence of unrecognized cerebral infarcts in patients with first-ever ischaemic stroke.
Methods:  We consecutively included patients who were admitted with first-ever stroke. Unrecognized cerebral infarct was defined as an ischaemic infarction or primary intracerebral hemorrhage on MRI irrelevant to the index stroke, without acute lesions on diffusion-weighted image.
Results:  Of the total 203 patients, 78 (39.4%) patients were observed as having unrecognized cerebral infarct. Patients with high-risk cardioembolic sources (e.g., atrial fibrillation) more frequently had unrecognized stroke than those without ( P  = 0.008, 21/36 [58.3%] vs. 57/167 [34.1%]). On univariate analysis, male sex ( P  = 0.027) and cardioembolic source ( P  = 0.008) were associated with the presence of unrecognized cerebral infarcts. After adjustment for gender, age and risk factors, the presence of cardioembolic sources independently increased the risk of unrecognized cerebral infarct ( P  = 0.002, odds ratio 3.56, 95% confidence interval 1.58–8.02). Regarding clinical outcome at 3 months, the presence of unrecognized cerebral infarct was not associated with the poor clinical outcome.
Conclusion:  In our study, the presence of cardioembolic sources was an independent risk factor for the unrecognized cerebral infarct in patients with first-ever stroke.     

Natural history of complications after intracerebral haemorrhage

Background and purpose:  Numerous trials of haemostatic and neuroprotective agents for intracerebral haemorrhage (ICH) have failed. We characterized the risk of complications after ICH in a trial-eligible patient population, to inform safety in future trials.
Methods:  We used the Virtual International Stroke Trials Archive database to identify placebo-treated patients with spontaneous ICH, who were not comatose at admission, where randomization took place within 4 h of symptom onset, and where serious complication and outcome data were available. We described the complications encountered and assessed whether the absence of common complications influenced attainment of good functional outcome (mRS ≤4) at 90 days using logistic regression.
Results:  Of 201 patients examined, 70.2% experienced at least one serious complication. Neurological complications occurred in 21%, infections amongst 11%, and thromboembolic complications in 2%. Extension of the haemorrhage occurred most frequently: its absence was a significant predictor of good functional outcome ( P  < 0.0001, adjusted OR for good functional outcome = 21.9, 95% CI: [5.5, 88.3]). Neither infection, nor cardiac, nor thromboembolic complications influenced functional outcome at 90 days.
Conclusions:  Three month outcome in ICH patients depends on initial stroke severity and on enlargement of the haemorrhage. Our results should inform safety in future clinical trials of putative ICH therapies.     

Hyperdense middle cerebral artery sign is associated with increased risk of hemorrhagic transformation after intravenous thrombolysis for patients with acute ischaemic stroke

Haemorrhagic transformation (HT) is an infrequent but serious complication of intravenous thrombolysis therapy (IVT) for acute ischemic stroke. The hyperdense middle cerebral artery sign (HMCAS) is a possible radiological predictor. We aimed to assess the association between HMCAS and HT in a retrospective study. We included all patients with acute anterior circulation ischaemic stroke who received IVT between October 2007 and December 2011. Baseline characteristics were collected, including demographics, stroke risk factors and stroke type. Presence of HMCAS on baseline CT scans was evaluated. Follow-up CT scans were examined for HT, categorised according to the European Australasian Acute Stroke Study (ECASS) classification. The presence of symptomatic intracerebral haemorrhage (sICH) was defined according to Safe Implementation of Thrombolysis in Stroke Monitoring Study (SITS–MOST) criteria. The association between HT and HMCAS was assessed by univariate and multivariate logistic regression analysis. We included 182 consecutive patients treated with IVT in this study. HMCAS was present in 70 patients (38.5%). Patients with HMCAS had higher baseline National Institutes of Health Stroke Scale scores (p < 0.001) and more frequent early ischaemic changes on baseline CT scan (p < 0.001) than those without HMCAS. We identified 49 instances (26.9%) of HT in 182 follow-up CT scans. HMCAS was associated with HT in univariate analysis (unadjusted odds ratio [OR] = 4.151, 95% confidence interval [CI]: 2.081–8.279, p < 0.001) and remained an independent risk factor of HT in multivariate analysis (adjusted OR = 2.691, 95% CI: 1.231–5.882, p = 0.013). There was no statistically significant difference in the frequency of sICH between the HMCAS group and the non-HMCAS group. We concluded that HMCAS is common in anterior circulation infarction and is independently predictive of HT after thrombolytic therapy.     

Diabetes and previous stroke: hazards for intravenous thrombolysis?

Background and purpose: Alteplase licensing approval in Europe does not advocate intravenous thrombolysis (IVT) for diabetic ischaemic stroke (IS) patients with previous cerebral infarction (PCI). Our aim was to assess whether concomitant diabetes mellitus (DM) and PCI are associated with symptomatic intracerebral haemorrhage (SICH) and poor outcome after IVT. Methods: Multicentre prospective registry, which included consecutive IVT‐treated, acute IS patients from January 2003 to December 2010. The frequency of SICH (SITS‐MOST criteria) and 3‐month outcomes (mRS) were compared between the following groups: (i) diabetic patients with PCI (DM+/PCI+); (ii) diabetic patients without PCI (DM+/PCI?); (iii) non‐diabetic patients with PCI (DM?/PCI+); and (iv) patients without diabetes or PCI (DM?/PCI?). Results: A total of 1475 patients were included. Thirty‐four patients (2.3%) had known DM and PCI, 258 (17.5%) were diabetics without PCI, and 119 (8.1%) had a PCI and no DM. Thirty‐six patients (2.6%) developed SICH, with no differences between groups (P = 985). Fifteen (40.9%) DM+/PCI+ patients, 113 (46.5%) DM+/PCI? patients, 47 (42%) DM?/PCI+ patients and 414 (40.9%) DM?/PCI? patients had mRS ≥ 3 at 3 months (P = 427). The presence neither of DM nor of PCI, nor their combination, had any impact on the risk of SICH or on outcome at 3 months after adjusting for age, stroke severity and glucose levels on admission. Conclusions: Acute IS diabetic patients with PCI who were treated with IVT had similar outcomes to patients without such history, with no increase in the rates of SICH. Thus, they should not be excluded from IVT only on the basis of DM and PCI.     

Bias in request for medical care and impact on outcome during office and non-office hours in stroke patients

Background and purpose:  We compared characteristics and treatment success of ischaemic stroke patients admitted during daytime on working days (office hours) with patients admitted on weekend or nighttime (non-office hours) to test if differences in presentation or restraints of medical care during non-office hours determine outcome in stroke patients.
Methods:  We analyzed a prospective stroke registry and grouped patients according to admission on office hours and non-office hours. Clinical state on admission, risk factors, sociodemographic items, complications, place of discharge, and clinical state on discharge were recorded.
Results:  A total of 37 396 stroke patients were evaluated. Onset–admission time on Monday was significantly elevated and on weekend significantly reduced. Number of patients with treatment success did not differ between patient groups whilst mortality within 7 days, proportion of embolic stroke, overall mortality and rate of complications where higher in patients admitted during non-office hours, rate of thrombolytic treatment was significantly higher during non-office hours. After adjustment for clinical state and admission latency, risk for severe outcome or death was independent from time of admission.
Conclusion:  Considering the fact that stroke patients admitted during non-office hours were in more severe clinical condition we found no differences in outcome. Fear of impaired access to sophisticated treatment options during non-office hours could be dispelled by the fact, that rate of thrombolytic treatment was even higher during night and weekend. Therefore, our data do not confirm a weekend effect or night effect on stroke treatment. Delay in request of medical care of mildly affected patients that suffer from stroke on weekends confirms need for educational efforts.     

Hyperdense middle cerebral artery sign is an ominous prognostic marker despite optimal workflow

Abul‐Kasim K, Brizzi M, Petersson J. Hyperdense middle cerebral artery sign is an ominous prognostic marker despite optimal workflow.
Acta Neurol Scand: DOI: 2010: 122: 132–139.
© 2009 The Authors Journal compilation © 2009 Blackwell Munksgaard. Objectives – To evaluate the association between the hyperdense middle cerebral artery sign (HMCAS) and the functional outcome on one hand, and different predictors such as the National Institutes of Health Stroke Scale (NIHSS), infarct size, ASPECTS Score, intracerebral hemorrhage, and mortality on the other hand. Material and methods – Retrospective analysis of 120 patients with MCA‐stroke treated with intravenous thrombolysis. We tested the association between HMCAS and NIHSS, infarct volume, ASPECTS, outcome, level of consciousness, different recorded time intervals, and the day/time of admission. Results – Seventy‐four percentage of patients treated with thrombolysis developed cerebral infarction. All patients with HMCAS (n = 39) sustained infarction and only 31% showed favorable outcome compared with 62% and 60%, respectively among patients without HMCAS (P < 0.001 and P = 0.002). There was statistically significant association between functional outcome and HMCAS (P = 0.002), infarct volume, NIHSS, and ASPECTS (P < 0.001). The time to treatment was 12 min shorter in patients who developed infarction (P = 0.037). Independent predictors for outcome were NIHSS and the occurrence of cerebral infarction on computed tomography for the whole study population, and infarct volume for patients who sustained cerebral infarction. Conclusions – Despite optimal workflow, patients with HMCAS showed poor outcome after intravenous thrombolysis. The results emphasize the urgent need for more effective revascularization therapies and neuroprotective treatment in this subgroup of stroke patients.     

Intravenous thrombolysis for ischemic stroke with hyperdense middle cerebral artery sign: A meta-analysis

Hyperdense middle cerebral artery sign (HMCAS) on admitting to neuroimaging is reported to have prognostic value for poor outcomes after thrombolysis, while evidence from studies comprising a sufficiently large sample size is limited. To detect prognostic predictors after thrombolysis could help improve therapeutic clinical strategies for acute ischemic stroke. We included prospective and retrospective studies of stroke patients that were treated with intravenous thrombolysis, in which functional outcomes (ie, a modified Rankin scale [mRS]) and systematic intracranial hemorrhage (sICH) were assessed in relation to HMCAS during pretreatment head CT. Random-effects models were used to calculate pooled risk ratios (RR) of poor outcomes and sICH for HMCAS patients as compared to patients without HMCAS. Eleven studies permitted identification of 11 818 patients. The risk of poor outcome at 3 months in the HMCAS-positive group was 1.56-fold the negative group (RR, 1.56; 95% CI 1.50-1.62; P < .001). The sICH risk when comparing both groups was found to be non-significant. Sensitivity analysis regarding studies performing thrombolysis within 3 hours also exhibited significant differences in their functional outcomes (RR, 1.56, 95% CI 1.49-1.62; P < .001) in patients with HMCAS as compared to non-HMCAS patients, although this was true for sICH risk. The presence of HMCAS on pretreatment CT predicts a poor outcome at 3 months after intravenous thrombolysis, while its relationship with the incidence of sICH was found to have no statistic value. Our study implies that more aggressive treatment should be considered for HMCAS patients.     

Risk and predictors of early epileptic seizures in acute cerebral venous and sinus thrombosis

We assessed the risk and determined predictors of early epileptic seizures (ES) in patients with acute cerebral venous and sinus thrombosis (CVST). A prospective series of 194 consecutive patients with acute CVST admitted to neurological wards in two German university hospitals was analysed for frequency of ES and in-hospital mortality. Demographic, clinical and radiological characteristics during the acute stage were retrospectively analysed for significant association with ES in univariate and multivariate analyses. During the acute stage, 19 patients (9.8%) died. Early symptomatic seizures were found in 86 patients (44.3%). Status epilepticus occurred in 11 patients (12.8%) of whom four died. Amongst patients with epileptic seizures, mortality was three times higher in those with status than in those without (36.4% and 12%, respectively). In multivariate logistic regression analysis, motor deficit [odds ratio (OR) 5.8; 95% CI 2.98–11.42; P  < 0.001], intracranial haemorrhage (OR 2.8; 95% CI 1.46–5.56; P  = 0.002) and cortical vein thrombosis (OR 2.9; 95% CI 1.43–5.96; P  = 0.003) were independent predictors of early epileptic seizures. Status epilepticus was an important source of morbidity and early mortality in patients with CVST in this study. Patients with focal motor deficits, cortical vein thrombosis and intracranial haemorrhage carried the highest risk for ES. Prophylactic antiepileptic treatment may be an option for these patients.     

Comparison of stroke ward care versus mobile stroke teams in the Hungarian stroke database project

Although previous studies have proved that both stroke wards and mobile stroke teams are considerably better than non-specialized stroke care, an unresolved debate in vascular neurology is whether or not stroke wards provide better outcomes in some specific cases to stroke victims. Our prospective, multicenter, cohort study compared dedicated stroke wards versus specialist stroke team care at general hospital wards in 11 centers nationwide for 8743 consecutive stroke events during 18 months. Twenty-eight-day case-fatality rate was 12.6% at stroke wards versus 15.2% at stroke teams for all patients ( P  = 0.002), and stroke ward care also predicted better outcome when analyzed with multivariate logistic regression model (odds ratio 1.701; confidence interval: 1.025–2.822). Case-fatality rates were not significantly different in patients with modified Rankin score ≥2 (case-fatality rate: 17.8% vs. 20.3%; P  = 0.163), and over 60 (case-fatality rate: 14.8% vs. 15.9%; P  = 0.250), however these patients were more probably at home after 4 weeks when treated at stroke wards (56.1% vs. 50.6%; P  = 0.03, and 69.5% vs. 64.5%; P  = 0.004). In our study, stroke ward admission provided lower case-fatality rate below 60 and for those independent prior to their strokes, and lower institutionalization over 60 and amongst previously dependent patients, when compared with stroke teams.     

Brachial arterial flow mediated dilation in acute ischemic stroke

Background and purpose:  Brachial arterial flow-mediated dilation (FMD) reflects endothelium-dependent vasodilation function. FMD is diminished in patients with endothelial dysfunction (ED). Our aim was to investigate the relationship between FMD and outcome for patients with acute ischemic stroke.
Methods:  We measured FMD in 120 consecutive patients (58.3% male, median age 73 years) with acute ischemic stroke within the first 48 h of onset of the stroke, using high-resolution ultrasonography. FMD was calculated as the relationship between basal diameter of the brachial artery before ( d ₁) and after ( d ₂) transient vascular occlusion (300 mmHg for 4 min) was measured using a sphygmomanometer (FMD =  d ₂ −  d ₁/ d ₁ × 100). Poor outcome was defined as modified Rankin Scale at 3 months >2. FMD was categorized according to ROC analysis and we defined ED as FMD ≤ 4.5%.
Results:  Thirty-three patients (27.5%) had ED. Median % FMD was 9.12 (7.48). FMD negatively correlated to stroke severity ( P  = 0.045). Median FMD was significantly lower [4.5 (2.3, 10.3) vs. 9.4 (5.6, 15.1), P  = 0.003] for patients with poor outcome ( n  = 38). The adjusted odds ratio of poor outcome for FMD ≤ 4.5% was 3.03 (95% CI, 1.09–27.3).
Conclusions:  Impaired FMD in patients with acute ischemic stroke is associated with poor outcome.     

The neuroprotection of prodromal transient ischaemic attack on cerebral infarction

Background and purpose:  To evaluate the potential neuroprotection against subsequent cerebral infarction conferred by a prodromal transient ischaemic attack (TIA).
Methods:  Various measures, including blood pressure, blood serum glucose, serum lipids, cardiovascular imaging and changes to NIHSS scores were evaluated upon admission and discharge for patients presenting with ischaemic stroke with or without prodromal TIA ( n  = 60 per group).
Results:  When all patients from each group were considered together, no significant group effects emerged. However, when the NIHSS difference scores from the prodromal TIA group were subdivided based on (i) prodromal TIA lasting up to 4 min; (ii) two prodromal TIA attacks and/or; (iii) prodromal TIA-stroke interval within 7 days separately, patients in subgroups 1 and 2 exhibited significantly better outcome on discharge. There was no significant effect found in subgroup three although this TIA group did show better outcome in considering the NIHSS changes.
Conclusions:  Prodromal TIA prior to cerebral infarction may result in an ischaemic tolerance effect. Moreover, the neuroprotection conferred by the TIA may be associated with the duration and the frequency of the TIA, although the relationship between the TIA-stroke interval and prognosis is not clear.     

The ipsilateral cortico-spinal tract is activated after hemiparetic stroke

Background and purpose:  The presence of a projection from the primary motor cortex to the ipsilateral muscles has been established in human, but whether this pathway contributes to functional recovery after stroke is unclear. We investigated whether the ipsilateral tract is activated in hemiparetic stroke.
Methods:  Motor-evoked potentials (MEPs) were simultaneously recorded from the bilateral trapezius or abductor digiti minimi (ADM) muscles after magnetic stimulation to the motor cortex in 40 acute stroke patients.
Results:  At rest, ipsilateral trapezius MEPs were recordable in none of the 24 normal controls, and in 38% of the patients after stimulation to the non-affected hemisphere ( P  < 0.001). With voluntary contraction, ipsilateral trapezius MEPs were elicited in 21% of the normal controls and 73% of the patients ( P  < 0.001). Ipsilateral ADM MEPs were rarely recordable in both controls (0%) and patients (3%). The presence of ipsilateral trapezius MEPs was associated with less severe paresis in the trapezius ( P  = 0.04) and deltoid ( P  = 0.07), but not in the more distal muscles.
Conclusions:  The ipsilateral cortico-spinal tract is acutely facilitated after stroke in the trunk or proximal muscles, but not in the hand muscles. Activation of such pathway appears to partly compensate motor dysfunction of the trunk/proximal muscles.     

Intravenous thrombolysis in patients with stroke attributable to small artery occlusion

Background: Intravenous thrombolysis (IVT) for stroke seems to be beneficial independent of the underlying etiology. Recent observations raised concern that IVT might cause harm in patients with strokes attributable to small artery occlusion (SAO). Objective: The safety of IVT in SAO‐patients is addressed in this study. Methods:  We used the Swiss IVT databank to compare outcome and complications of IVT‐treated SAO‐patients with IVT‐treated patients with other etiologies (non‐SAO‐patients). Main outcome and complication measures were independence (modified Rankin scale ≤2) at 3 months, intracranial hemorrhage (ICH), and recurrent ischaemic stroke. Results: Sixty‐five (6.2%) of 1048 IVT‐treated patients had SAO. Amongst SAO‐patients, 1.5% (1/65) patients died, compared to 11.2% (110/983) in the non‐SAO‐group (P = 0.014). SAO‐patients reached independence more often than non‐SAO‐patients (75.4% versus 58.9%; OR 2.14 (95% CI 1.20–3.81; P = 0.001). This association became insignificant after adjustment for age, gender, and stroke severity (OR 1.41 95% CI 0.713–2.788; P = 0.32). Glucose level and (to some degree) stroke severity but not age predicted 3‐month‐independence in IVT‐treated SAO‐patients. ICHs (all/symptomatic) were similar in SAO‐ (12.3%/4.6%) and non‐SAO‐patients (13.4%/5.3%; P > 0.8). Fatal ICH occurred in 3.3% of the non‐SAO‐patients but none amongst SAO‐patients. Ischaemic stroke within 3 months after IVT reoccurred in 1.5% of SAO‐patients and in 2.3% of non‐SAO‐patients (P = 0.68). Conclusion: IVT‐treated SAO‐patients died less often and reached independence more often than IVT‐treated non‐SAO‐patients. However, the variable ‘SAO’ was a dependent rather than an independent outcome predictor. The absence of an excess in ICH indicates that IVT seems not to be harmful in SAO‐patients.     

Impact of seizures on morbidity and mortality after stroke: a Canadian multi-centre cohort study

Introduction:  Limited information is available about the impact of seizures on stroke outcome, health care delivery and resource utilization.
Objective:  To determine whether the presence of seizures after stroke increases disability, mortality and health care utilization (length of hospital stay, ICU admission, consults, discharge to a long-term care facility).
Methods:  This cohort study included consecutive patients with acute stroke between July 2003 and June 2005 from the Registry of the Canadian Stroke Network (RCSN), the largest clinical database of patients in Canada with acute stroke seen at selected acute care hospitals. We compared clinical characteristics and outcomes amongst patients experiencing stroke without and with seizures occurring during inpatient stay. Main outcome measures included: case-fatality, disability at discharge, length-of-stay, and discharge disposition. A logistic regression analysis was used to determine whether the presence of seizures was associated with poor stroke outcomes.
Results:  Amongst 5027 patients included in the study; seizures occurred in 138 (2.7%) patients with stroke. Patients with seizures had a higher mortality at 30-day (36.2% vs. 16.8%, P  < 0.0001) and at 1-year post-stroke (48.6% vs. 27.7%, P  < 0.001), longer hospitalization, and greater disability at discharge ( P  < 0.001). Multivariate analysis revealed that stroke severity, hemorrhagic stroke, and presence of neglect were associated to occurrence of seizures after stroke.
Conclusions:  The presence of seizures after stroke was associated with increased resources utilization, length of hospital stay, whilst decreasing both 30-day and 1-year survival. Quality improvement strategies targeting patients with seizures may help optimize the management of this subgroup of more disabled patients.     

Haemorrhagic pure motor stroke

To describe the clinical characteristics of haemorrhagic pure motor stroke (PMS). Twelve patients with haemorrhagic PMS were identified. Haemorrhagic PMS accounted for 3.2% of all cases of pure motor hemiparesis ( n  = 380) and 3.3% of intracerebral haemorrhage ( n  = 364) entered in the database. When compared with PMS of ischaemic origin, patients with haemorrhagic PMS were more likely to be younger (62.2 vs. 75.2 years, P  = 0.003) and to have headache (33% vs. 6.3%, P  =0.007) and thalamus involvement (25% vs. 2.4%, P  = 0.005). Limb weakness (100% vs. 74.1%; P  = 0.03), involvement of the internal capsule (50% vs. 17.3%, P  = 0.012) and symptom free at discharge (25% vs. 3.7%, P  = 0.012) were significantly more frequent in patients with haemorrhagic PMS than in the remaining cases of haemorrhagic stroke, whereas nausea and vomiting (0% vs. 25.9%, P  = 0.03), altered consciousness (0% vs. 42.9%, P  = 0.001), sensory symptoms (8.3% vs. 46.9%, P  =0.007) and ventricular haemorrhage (0% vs. 26.1%, P  = 0.028) were significantly less frequent. Haemorrhagic PMS is a very infrequent stroke subtype. Headache at stroke onset may be useful sign for distinguishing haemorrhagic PMS from other causes of lacunar stroke. There are important differences between haemorrhagic PMS and the remaining intracerebral haemorrhages.     

Anterior choroidal artery infarction: a clinical, etiologic and prognostic study

Objectives –  To analyze the clinical, etiologic and prognostic profile of anterior choroidal artery (AChA) infarcts.
Methods –  42 consecutive patients with AChA infarction were included. Symptoms, etiology and scores on neurological and functional scales were analyzed on admission, discharge and at 3-month follow-up. A comparative study was performed between deep ( n  = 23) and deep + superficial ( n  = 19) infarcts.
Results –  Lacunar syndrome was present in 83.3% of patients. Etiology was large-vessel disease in 38.1% and cryptogenic in 38.1%. Ten patients had a National Institute of Health Stroke Scale score >7 on admission. At discharge, 45.3% had an modified Rankin Scale >2 (35.7% after 3 months). Infarcts involving superficial territory were more severe at admission ( P  = 0.034) and were associated with a worse functional status at discharge ( P  = 0.0008).
Conclusion –  AChA infarcts usually present with lacunar syndrome, although they are often not lacunar infarcts. At discharge, almost half of the patients are dependent in their activities of daily living, and most remain so at 3-month follow-up. Infarcts involving superficial territory are associated with worse prognosis.     

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.     

Safe implementation of thrombolysis in stroke-monitoring study in Italy

Background and purpose:  The safe implementation of thrombolysis in stroke-monitoring (SITS-MOST) study was an unique opportunity to test in Italy, where only few centres were expert in thrombolytic treatment before, safety and efficacy of i.v. alteplase within 3 h of ischaemic stroke outside the setting of clinical trials.
Methods:  In Italy to participate in the study the clinical centres had to possess organizational and structural characteristics certified by Regional Health Authorities.
Results:  Seventy-one centres were activated, 56 (79%) treated patients of which 41 (73%) had never used thrombolysis before the study. Globally, 586 patients were included. Baseline median National Institute of Health Stroke Scale of Italian patients was 13 vs. 12 in other European centres ( P  = 0.0001). Symptomatic intracerebral haemorrhage as per the NINDS/Cochrane definition, mortality and independence (modified Rankin Scale 0–2) rates at 3 months occurred respectively in 6.7% (95% CI: 4.8–9.1), 11.7% (9.2–14.6) and 51.6% (47.4–55.7) of Italian patients compared with 7.3% (6.7–8.0) ( P  = 0.56), 11.2% (10.4–12.1) ( P  = 0.75) and 55.1% (53.8–56.4) ( P  = 0.09) in the European patients and in 8.6% (40/65; 6.3–11.6), 17.3% (14.1–21.1) and 50.1% (44.5–54.7) of the patients treated in the pooled randomized controlled trials.
Conclusions:  The SITS-MOST study showed that in Italy i.v. alteplase is safe and effective in routine clinical use also in non-expert centres.     

Thrombectomy or intravenous thrombolysis in patients with NIHSS of 5 or less?

Background and purposeTo compare outcomes of minor stroke patients with intracranial vessel occlusions (IVO) underwent mechanical thrombectomy (MT) versus those treated with intravenous thrombolysis alone (IVT).MethodsWe retrospectively reviewed two large prospective stroke databases from two European centers searching for patients admitted with minor stroke (i.e. NIHSS Score░≤░5), baseline mRS░=░0 and occlusion of the M1–M2 segment of the middle cerebral artery (MCA). Groups receiving (A) IVT alone and (B) MT+/-IVT were compared. Primary outcome measures were MT safety, successful recanalization rate (mTICI 2b-3) and NIHSS shift (discharge NIHSS minus admission NIHSS); secondary outcomes included discharge rates and excellent outcome (mRS 0-1) at 3 months. Univariate and multivariate analyses were performed.ResultsThirty-two patients were enrolled in Group B (19░MT alone; 13 MT░+░IVT) and 24 in Group A. Successful recanalization (mTICI 2b-3) was obtained in 100% of cases in Group B vs 38% in Group A. Symptomatic hemorrhagic transformation rate did not differ between the two groups. Multivariate analysis reported MT as the only predictor of early (<░12░h) favorable NIHSS shift and lower NIHSS at discharge. Moreover, discharge at home and excellent outcome at 3-month follow-up were statistically associated with MT.ConclusionsMT in patients with minor strokes and intracranial vessel occlusion (IVO) is safe and can determine a rapid improvement of NIHSS Score. MT seems also associated with a higher rate of patients discharged at home after hospitalization and better clinical outcome at 3-month follow-up. Larger randomized trials are warranted to confirm these results.