Endovascular treatment for acute ischemic stroke at a primary stroke center: First results of the Perpignan center

IntroductionConverting a high-volume primary stroke center (PSC) into a stroke center that can perform emergency endovascular treatment (EVT) could reduce the time to thrombectomy. We report the first results of a newly established EVT facility at the Perpignan PSC and their comparison with the targets defined by the established guidelines.Patients and methodFor this comprehensive observational study, data of patients with acute ischemic stroke (AIS) due to proximal large vessel occlusion (LVO) and treated by EVT at the Perpignan PSC from December 5, 2019 to September 15, 2020 were extracted from an ongoing prospective database.ResultsDuring the study period, 37 patients underwent EVT at the Perpignan PSC. The median (range) symptom-onset to recanalization time was 262 min (100–485 min). The median (range) intra-hospital times were: 20 min (2–58 min) for door-to-imaging, 57 min (30–155 min) for imaging-to-puncture, 55 min (15–180 min) for puncture-to-recanalization, and 137 min (59–319 min) for door-to-recanalization. At 3 months post-AIS, the favorable outcome (modified Ranking Score: 0–2) rate was 50% and the mortality rate was 19.4%. These results are comparable to those of previous clinical trials, and meet the targets defined by the current consensus statements for EVT.Discussion and conclusionOur results show the feasibility and safety of EVT in a PSC for patients with AIS due to LVO. The implementation of this strategy may be important for shortening the time to thrombectomy.     

Recanalisation success is independent of ASPECTS in predicting outcomes after intra-arterial therapy for acute ischaemic stroke

Intra-arterial (IA) therapy for stroke is an increasingly utilised management approach for acute ischaemic stroke. We aimed to correlate radiological characteristics and recanalisation success with radiological and functional outcomes at 90 days in patients treated with IA therapy. This was a single centre, retrospective study investigating the correlation between pre-procedural Computed Tomography-Angiogram Source Image (CTA-SI) Alberta Stroke Program Early Computed Tomography Score (ASPECTS), recanalisation success, and functional outcome at 90 days in patients with an acute ischaemic stroke from 2007–2012. Outcome measures were pre-procedural non-contrast computed tomography (NCCT), CTA-SI, and post-procedural NCCT ASPECTS that were obtained and analysed by three blinded reviewers, recanalisation success (Thrombolysis in Cerebral Infarction [TICI] 2b–3) and favourable clinical outcome (90 day modified Rankin scale [mRS] score ⩽ 2). Forty-four patients satisfied the inclusion criteria. The mean age was 64.2 years (standard deviation: 14.9; median: 66.5; interquartile range [IQR]: 54.5–76.5). The median National Institutes of Health Stroke Scale score was 17 (IQR: 13.5–20). Twenty-one (47.7%) patients achieved a mRS score ⩽ 2. The 90 day mortality rate was 25.0% (n = 11). Of the patients who achieved TICI 2b–3, 65.5% (19/29) achieved mRS ⩽ 2. There was a statistically significant association between recanalisation success (TICI ⩾ 2b) and favourable neurological outcome at 90 days (odds ratio [OR] 25.22, 95% confidence interval [CI]: 2.86–222.37, p < 0.005). Patients with high pre-procedural CTA-SI ASPECTS are significantly more likely to have high post-procedural NCCT score (OR 23.36, 95% CI: 3.26–166.92, p = 0.002). Recanalisation success was strongly associated with good clinical outcome, unaffected by known predictive factors, which included age and stroke severity. This association was unattenuated by CTA-SI ASPECTS.     

Number of Stent Retriever Passes Associated with Clinical Outcome After Mechanical Thrombectomy in Acute Ischemic Stroke

ObjectiveTo evaluate the association between the number of stent retriever (SR) passes and clinical outcome after mechanical thrombectomy (MT) in patients with acute ischemic stroke(AIS).MethodsWe retrospectively analyze data collected from consecutive patients with large vessel occlusion (LVO) in anterior circulation treated with MT. Baseline characteristics, number of SR passes, symptomatic intracranial hemorrhage (sICH), clinical outcome measured by modified Rankin Scale (mRS) at 90 days after MT were collected. Multivariate logistic regression analysis was performed to assess the association between number of SR passes and patients’ clinical outcome.Results134 patients with LVO achieved successful reperfusion (mTICI 2B/3) were enrolled. Univariate analysis showed that patients with favorable outcomes were less likely to need more than three passes of SR (9.8%vs39.7%, p = 0.001). In a multivariable analysis, baseline NIHSS score (OR 0.922, 95%CI 0.859∼0.990, p = 0.025), more than three passes of SR (OR 0.284, 95%CI0.091∼0.882, p = 0.030) and symptomatic intracranial hemorrhage (OR 0.116,95%CI0.021∼0.650, p = 0.014) each independently predicted poor outcome after MT at 90 days.ConclusionThe need for more than three passes of SR may be used as an independent predictor of poor outcome after MT in patients with acute ischemic stroke at 90 days.     

Estimated number of eligible patients for mechanical thrombectomy based on NIHSS and population-based Brest stroke registry

BackgroundSince 2015, mechanical thrombectomy (MT) is indicated as a treatment for patients with large vessel occlusion (LVO) at the acute phase of ischemic stroke. However, the number of stroke patients eligible for MT is poorly known.ObjectiveThe objective of our study was to estimate the number of patients eligible for thrombectomy within the first 24 hours of an ischemic stroke, based on the clinical National Institute of Health Stroke Scale (NIHSS).MethodOur study concerned all ischemic strokes which occurred between January 2013 and December 2016 recorded in the population-based Brest Stroke Registry (BSR). Based on positive predictive value and negative predictive value from articles evaluating the performance of a defined NIHSS threshold to identify LVO, we first estimated the frequency of patients with LVO and then the frequency of patients eligible for MT depending on pre-stroke modified Rankin score (mRS). Our results were extrapolated to regions of metropolitan France. Two scenarios were considered: one called “stringent criteria” with mRS ≤ 1 and one called “real-life” criteria with mRS ≤ 2.ResultWe analyzed data from 2,025 ischemic strokes with symptom onset ≤ 24 hours. No statistical difference between patient characteristics according to the time of hospital admission (≤ 6H vs. 6–24H) was observed. Based on NIHSS scores, between 23.90% and 44.20% of ischemic strokes admitted within the first six hours had LVO clinical characteristics. Among them, 14.53% to 26.87% met the ``stringent eligibility'' criteria for MT and 16.9 to 31.25% for ``real-life'' criteria. Eligible patients represented 6.32% to 11.70% of all ischemic strokes, irrespective of admission time. In France, 75 to 162 persons per million inhabitants per year were eligible for endovascular therapy, depending on including criteria. Based on activity levels recorded by the French Neuroradiology Society (SFNR) in 2018, the estimated needed increase in MT showed a heterogeneous pattern region-by-region, with the greatest need in Brittany, Pays de la Loire, and Corsica.ConclusionBased on NIHSS, our study provides coherent information concerning the estimated number of MT procedures to be performed in France: 4,877 to 10,494 ischemic strokes would be eligible each year in metropolitan France compared to the 6,596 thrombectomy procedures actually performed in 2018. Depending on the region, an estimated 10–20% to 90–100% increase in MT activity would be necessary to meet patient needs. These data suggest that there is still room for improvement in thrombectomy activity, particularly in certain regions of France, to allow equal access to MT to the entire French population.     

Mechanical thrombectomy: Determining the proportion of eligible acute ischemic stroke patients in the cohort of single academic stroke center

Background and purpose

Mechanical thrombectomy (MT) is now well-established treatment method for selected patients with acute ischemic stroke (AIS) and efforts are being made to incorporate it into the systems of stroke care. Our objective is to assess the number of AIS individuals eligible for MT in the cohort of single academic stroke center.

A regional strategy to decrease the time to thrombectomy in patients with low probability of treatment by thrombolysis

Background and purposeThe best transportation strategy for patients with suspected large vessel occlusion (LVO) is unknown. Here, we evaluated a new regional strategy of direct transportation to a Comprehensive Stroke Center (CSC) for patients with suspected LVO and low probability of receiving intravenous thrombolysis (IVT) at the nearest Primary Stroke Center (PSC).MethodsPatients could be directly transported to the CSC (bypass group) if they met our pre-hospital bypass criteria: high LVO probability (i.e., severe hemiplegia) with low IVT probability (contraindications) and/or travel time difference between CSC and PSC < 15 minutes. The other patients were transported to the PSC according to a “drip-and-ship” strategy. Treatment time metrics were compared in patients with pre-hospital bypass criteria and confirmed LVO in the bypass and drip-and-ship groups.ResultsIn the bypass group (n = 79), 54/79 (68.3%) patients met the bypass criteria and 29 (36.7%) had confirmed LVO. The positive predictive value of the hemiplegia criterion for LVO detection was 0.49. In the drip-and-ship group (n = 457), 92/457 (20.1%) patients with confirmed LVO met our bypass criteria. Among the 121 patients with bypass criteria and confirmed LVO, direct routing decreased the time between symptom discovery and groin puncture by 55 minutes compared with the drip-and-ship strategy (325 vs. 229 minutes, P < 0.001), without significantly increasing the time to IVT (P = 0.19).ConclusionsOur regional strategy led to the correct identification of LVO and a significant decrease of the time to mechanical thrombectomy, without increasing the time to IVT, and could be easily implemented in other territories.     

Influence of Thrombocytopenia on the Outcome of Mechanical Thrombectomy in Patients with Acute Ischemic Stroke

ObjectivesMechanical thrombectomy (MT) has become leading treatment option for acute ischemic stroke (AIS) due to large vessels occlusion (LVO). Platelet counts may affect outcome in patients with AIS or transient ischemic attack. The aim of our study was to determine the influence of thrombocytopenia on the safety and efficacy of MT in patients with AIS due to anterior circulation LVO.Materials and methodsThis study included 127 consecutive adult patients with AIS due to anterior circulation LVO who underwent MT. The patients were divided into 2 groups based on initial platelet count: with thrombocytopenia (<150 × 10⁹/L) and without thrombocytopenia (≥150 × 10⁹/L). Primary safety outcome was symptomatic intracerebral haemorrhage (SICH), while secondary safety outcome was stroke-related mortality. Efficacy outcome was functional independence, defined as modified Rankin Scale (mRS) score 0-2. Follow- up time was 90 days.ResultsInitial thrombocytopenia (<150 × 10⁹/L) was detected in 19 (15%) patients. Multivariable analysis showed that initial thrombocytopenia did not increase the risk of SICH and did not affect the short-term functional outcome (p = 0.587). However, initial thrombocytopenia increased the risk for stroke-related mortality (aOR 3.639, 95% CI 1.079-12.641, p = 0.037). The main cause of mortality in the group with thrombocytopenia was malignant cerebral infarction (44.4%).ConclusionsThrombocytopenia does not affect the efficacy and the risk of SICH in patients with AIS caused by anterior circulation LVO treated with MT. However, the risk of mortality is higher in patients with thrombocytopenia, mainly due to malignant cerebral infarction.     

Comparison of magnetic resonance angiography techniques to brain digital subtraction arteriography in the setting of mechanical thrombectomy: A non-inferiority study

IntroductionWe performed a non-inferiority study comparing magnetic resonance angiography (MRA) techniques including contrast-enhanced (CE) and time-of-flight (TOF) with brain digital subtraction arteriography (DSA) in localizing occlusion sites in acute ischemic stroke (AIS) with a prespecified inferiority margin taking into account thrombus migration.Materials and methodsHIBISCUS-STROKE (CoHort of Patients to Identify Biological and Imaging markerS of CardiovascUlar Outcomes in Stroke) includes large-vessel-occlusion (LVO) AIS treated with mechanical thrombectomy (MT) following brain magnetic resonance imaging (MRI) including both CE-MRA and TOF-MRA. Locations of arterial occlusions were assessed independently for both MRA techniques and compared to brain DSA findings. Number of patients needed was 48 patients to exclude a difference of more than 20%. Discrepancy factors were assessed using univariate general linear models analysis.ResultsThe study included 151 patients with a mean age of 67.6 ± 15.9 years. In all included patients, TOF-MRA and CE-MRA detected arterial occlusions, which were confirmed by brain DSA. For CE-MRA, 38 (25.17%) patients had discordant findings compared with brain DSA and 50 patients (33.11%) with TOF-MRA. The discordance factors were identical for both MRA techniques namely, tandem occlusions (OR = 1.29, P = 0.004 for CE-MRA and OR = 1.61, P < 0.001 for TOF-MRA), proximal internal carotid artery occlusions (OR = 1.30, P = 0.002 for CE-MRA and OR = 1.47, P < 0.001 for TOF-MRA) and time from MRI to MT (OR = 1.01, P = 0.01 for CE-MRA and OR = 1.01, P = 0.02 for TOF-MRA).ConclusionBoth MRA techniques are inferior to brain DSA in localizing arterial occlusions in LVO-AIS patients despite addressing the migratory nature of the thrombus.     

Factors affecting the outcome of delayed intravenous thrombolysis (> 4.5 hours)

IntroductionEvidence of the intravenous tissue plasminogen activator (tPA) efficacy beyond the 4.5 hours window is emerging. We aim to study the factors affecting the outcome of delayed thrombolysis in patients of clear onset acute ischemic stroke (AIS).MethodsData of patients with AIS who received intravenous thrombolytic after 4.5 hours were reviewed including: demographics, risk factors, clinical, laboratory, investigational and radiological data, evidence of mismatch, treatment type and onset, National Institutes of Health Stroke Scale (NIHSS) score at baseline, 24 hours, 7 days after thrombolysis and before discharge, and 3 months follow-up modified Rankin Scale (mRS).ResultsWe report 136 patients treated by intravenous tPA between 4.53 and 19.75 hours with average duration of 5.7 h. The ASPECT score of our patients was ≥ 7. Sixty-four cases showed intracranial arterial occlusion. Perfusion mismatch was detected in 117 (84.6%) patients, while clinical imaging mismatch was detected in 19 (15.4%). Early neurological improvement after 24 hours occurred in 114 (83.8%) patients. At 90 days, 91 patients (67%) achieved good outcome (mRS 0–2), while 45 (33%) had bad outcome (mRS 3–6). Age, endovascular treatment, NIHSS, AF, and HT were significantly higher in the bad outcome group. Age (P = 0.001, OR: 1.099, 95% CI: 1.042–1.160) and baseline NIHSS were predictive of the poor outcome (P = 0.002, OR: 1.151, 95% CI: 1.055–1.256). The best cutoff value of age was 72.5 with AUC of 0.76, sensitivity 73.3% and specificity 60.4%. While for NIHSS at admission, the cutoff value of 7 showed the best results with AUC of 0.73, sensitivity 71.1% and specificity 63.7%. Combination of age and admission NIHSS raised the sensitivity and specificity to 84.4% and 63.7%, respectively.ConclusionIncreased age and admission NIHSS may adversely affect the outcome of delayed thrombolysis and narrow the eligibility criteria. Age and baseline NIHSS based stratification of the patients may provide further evidence as regards the efficacy of the delayed thrombolysis.     

External validation of TICI-ASPECTS-glucose score as a predictive model for symptomatic intracranial hemorrhage following mechanical thrombectomy

IntroductionThe indication for mechanical thrombectomy for acute ischemic stroke (AIS) secondary to large vessel occlusion has substantially increased in the past few years, but predictors of symptomatic intracranial hemorrhage (sICH) remain largely unstudied. A recent study assessing these predictors, led to the development of the TICI-ASPECTS-glucose (TAG) score, an internally validated model to predict sICH following thrombectomy.MethodsTo externally validate this scoring system and identify other potential risk factors for hemorrhagic conversion following endovascular therapy for AIS, 420 consecutive patients treated with mechanical thrombectomy from 2014-2017 were retrospectively reviewed. Data were collected pertaining to admission factors, procedural metrics, and functional outcomes. The components comprising the TAG score consist of modified thrombolysis in cerebral infarction (mTICI) score (mTICI 0-2a=2 points; 2b-3=0 points), Alberta stroke program early CT (ASPECTS) score (<6=4 points, 6-7=2 points, ≥8=0 points), and glucose (≥150 mg/dL=1 point, <150 mg/dL=0 points). Statistical analyses including univariate analysis, logistic regression analysis, and area under the receiver-operating curve (AUROC) were performed to validate the predictive capability of the model.ResultsThe patients with sICH presented with lower ASPECTS (8.13±1.55 v 9.16±1.24, p < 0.001), but no significant correlation with mTICI scores and admission glucose was observed. Decreasing ASPECTS correlated with increased risk of sICH (OR 1.57, 95% CI 1.25-1.96, p < 0.001), and increasing TAG score was associated with increased sICH (OR 1.46, 95% CI 1.11-1.94, p < 0.01). AUROC of the model was 0.633. Stratifying patients into low (TAG 0-2), intermediate,^3,4 and high^5-7 risk groups identified similar results to the original study with sICH risks of 5.2%, 10.5%, and 33.3%, respectively.ConclusionThe TICI-ASPECTS-glucose (TAG) score adequately predicts sICH following mechanical thrombectomy, and appropriately stratifies individual patient risk. Further inclusion of additional predictors of sICH would likely yield a more robust model.     

Recanalisation success is associated with good clinical outcome despite advanced age and stroke severity in patients treated with the Solitaire stentriever

Intravenous recombinant tissue plasminogen activator is associated with significant recanalisation failure in the setting of large artery occlusion. Endovascular treatment by stentriever achieves improved rates of recanalisation but its impact on clinical outcomes remains unclear. We hypothesise that successful recanalisation, unattentuated by age and stroke severity, is associated with improved clinical outcomes in patients treated with the Solitaire stentriever (ev3 Endovascular, Plymouth, MN, USA). We conducted a retrospective study of 60 consecutive acute ischaemic stroke patients treated with the Solitaire stentriever. The data included demographics, vascular risk factors, ictal onset time, National Institutes of Health Stroke Scale (NIHSS) score at presentation, angiographic findings, post-procedure imaging, and clinical follow-up. Recanalisation success was defined as a thrombolysis in cerebral infarction score (TICI) ⩾ 2b. Good clinical outcome was defined as a modified Rankin Scale score (mRS) ⩽ 2 at 3 months. Of the 60 patients, the mean age was 64.1 (standard deviation 13.4) years and 68.3% were men. Median NIHSS score at presentation was 18 (interquartile range 14–22). Successful recanalisation (TICI ⩾ 2b) was achieved in 44 patients (73.3%). Of these 44 patients, 25 patients (56.8%) achieved mRS ⩽ 2 at 3 months. Multiple logistic regression showed significant association between recanalisation success and improved clinical outcome (p = 0.019). Of all patients, four (6.7%) developed symptomatic intracranial haemorrhage. Overall mortality was 28.3%. In conclusion, the Solitaire stentriever was associated with improved recanalisation rates. We showed that successful recanalisation is associated with good clinical outcomes after adjustments for age, sex and stroke severity.     

High glycemic variability: An underestimated determinant of stroke functional outcome following large vessel occlusion

Background and purposeEarly glycemic variability (GV) in diabetic patients is a poor prognosis factor following cardiovascular events. However, its influence on the course of acute ischemic stroke (AIS) with large vessel occlusion remains unclear. We investigated the relationship between high GV during acute stroke and three-month functional outcome among patients treated with combined intravenous thrombolysis and endovascular therapy for large vessel occlusion.MethodsA single-center retrospective analysis of AIS patients with proximal intracranial occlusion who underwent thrombolysis and mechanical thrombectomy between January 2015 and May 2017. Early GV was assessed using standard deviation (SD) of blood glucose levels for the first 24 hours. The main outcome was functional status at three months as defined by the modified Rankin scale (mRS). Secondary outcomes were change in NIHSS score from baseline to 24 hours and occurrence of severe hemorrhagic transformation. Multivariate logistic regression analyses including GV, admission glycemia and mean glycemia were performed.ResultsAmong the 93 patients evaluated, 26 had early high GV (≥ 20.9 mg/dl). High GV was associated with poor functional outcome (OR = 8.00; 95%CI [1.34–47.89]; P = 0.02) unlike admission glycemia and mean glycemia (OR = 2.92; 95%CI [0.51–16.60]; P = 0.23 and OR = 0.36; 95%CI [0.05-2.6]; p = 0.31, respectively). High GV was not associated with NIHSS at 24 hours or hemorrhagic transformation.ConclusionAcute high GV contributes to poorer functional outcome following AIS related to large vessel occlusion and should be considered as a new target in acute stroke management.     

A randomized pilot study of patients with tandem carotid lesions undergoing thrombectomy

Background and purposeThe optimal management of patients with tandem lesions (TL), or cervical internal carotid artery (c-ICA) steno-occlusive pathology and ipsilateral intracranial occlusion, who are undergoing endovascular thrombectomy (EVT) remains unknown. We sought to establish the feasibility of a trial designed to address this question.Materials and methodsThe Endovascular Acute Stroke Intervention (EASI) study was a single-centre randomized trial comparing EVT to medical therapy for large-vessel occlusion stroke. Patients with TL receiving EVT were randomly allocated to acute c-ICA stenting or no stenting. The primary outcome was the proportion of patients with a modified Rankin Scale (mRS) score of 0–2 at 90 days. Safety outcomes were symptomatic intracranial hemorrhage (sICH) at 24 hours and mortality at 90 days.ResultsOf 301 patients included in EASI between 2013 and 2018, 24 (8.0%) with TL were randomly allocated to acute stenting (n = 13) or no stenting (n = 11). Baseline characteristics were balanced. Eight (61.5%; 95% CI 35.5%–82.3%) and 7 (63.6%; 95% CI 35.4%–84.9%) patients, respectively, had a favorable outcome (mRS 0–2; P = 1.0). One non-stented patient had a symptomatic intracerebral hemorrhage.ConclusionsThis pilot trial of patients with TL undergoing EVT suggests that a sufficiently powered larger TL trial comparing acute c-ICA stenting to no stenting is feasible.Clinical Trial RegistrationURL: http://www.clinicaltrials.gov. Unique identifier: NCT02157532.     

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.     

Stent retriever thrombectomy for acute ischemic stroke: A systematic review and meta-analysis of randomized controlled trials,including THRACE

Background and purpose

Endovascular thrombectomy has become the reference therapy for patients with large vessel occlusion (LVO). However, no meta-analysis including the THRACE Trial has yet been reported. Thus, the present review assessed the outcomes of stent retriever thrombectomy added to medical care compared with medical care alone in LVO patients.

A comparison of relative-frequency and threshold-hunting methods to determine stimulus intensity in transcranial magnetic stimulation

ObjectiveStimulation intensity (SI) in transcranial magnetic stimulation is commonly set in relation to motor threshold (MT), or to achieve a motor-evoked potential (MEP) of predefined amplitude (usually 1 mV). Recently, IFCN recommended adaptive threshold-hunting over the previously endorsed relative-frequency method. We compared the Rossini–Rothwell (R–R) relative-frequency method to an adaptive threshold-hunting method based on parameter estimation by sequential testing (PEST) for determining MT and the SI to target a MEP amplitude of 1 mV (I_1 mV).MethodsIn 10 healthy controls we determined MT and I_1 mV with R–R and PEST using a blinded crossover design, and performed within-session serial PEST measurements of MT.ResultsThere was no significant difference between methods for MT (52.6 ± 2.6% vs. 53.7 ± 3.1%; p = 0.302; % maximum stimulator output; R–R vs. PEST, respectively) or I_1 mV (66.7 ± 3.0% vs. 68.8 ± 3.8%; p = 0.146). There was strong correlation between R–R and PEST estimates for both MT and I_1 mV. R–R required significantly more stimuli than PEST. Serial measurements of MT with PEST were reproducible.ConclusionsPEST has the advantage of speed without sacrificing precision when compared to the R–R method, and is adaptable to other SI targets.SignificanceOur results in healthy controls add to increasing evidence in favour of adaptive threshold-hunting methods for determining SI.     

Chronic kidney disease is independently associated with acute recurrent cerebral infarct in patients with atrial fibrillation

Background and purposeThe present study aimed to determine the frequency and time of recurrent cerebral infarct (RCI) in patients with acute ischemic stroke (AIS) and atrial fibrillation (AF), and to clarify associated factors.MethodsWe retrospectively assessed and compared the clinical features of 79 consecutive patients (male, n = 56; median age, 75 y; median baseline NIHSS, 4) who were hospitalized due to AIS accompanied by AF, and who did or did not develop RCI between January 2012 and March 2015.ResultsDirect oral anticoagulants were administered to 59% of the patients after a median of two days from the onset of the index stroke. Stroke recurred in 10 (13%) of the 79 patients about 5 days after admission. The proportion of men was lower (30% vs. 77%, P = 0.005) and the patients were older (82 vs. 75 y, P = 0.049) in the group with RCI. Chronic kidney disease was significantly more prevalent in the group with RCI (50% vs. 16%, P = 0.025) and independently associated with RCI (OR, 6.59; 95%CI, 1.19–36.63; P = 0.031).ConclusionsWe found that RCI frequently develops about 5 days after admission in patients with AIS and AF and that chronic kidney disease is independently associated with RCI.     

Thrombolysis safety and effectiveness in acute ischemic stroke patients with pre-morbid disability

IntroductionRecombinant tissue plasminogen activator (rt-PA) is the first-line therapy demonstrated to be safe and effective in acute ischemic stroke. People with pre-existing severe dementia or physical disability are usually excluded from rt-PA. The aim of our study was to investigate rt-PA safety and effectiveness in acute stroke with pre-existing disability (mRS ≥ 2).MethodsThe study encompassed 35 acute ischemic stroke patients with mRS ≥ 2 treated with rt-PA. In order to assess the differences in clinical outcome in three disability groups (mRS = 2; 3; 4/5), the following parameters were evaluated: intracerebral hemorrhage, mortality, NIHSS, ΔNIHSS and mRS.ResultsBaseline-NIHSS and age were not significantly different among groups. Mortality was higher in the pre-morbid mRS 4/5 group (44%) than in the pre-morbid mRS 2 (16.7%) and mRS 3 groups (21.4%). In survived patients, median ΔNIHSS% was higher in the mRS 2 and 3 groups (-63.3% and −92.3%, respectively) than in the mRS 4/5 group (−9.1%). The 247 rt-PA treated subjects with mRS < 2 in the same period showed lower mortality rate (4.7%), lower sICH (5%), lower mRS at discharge (median 1; range 0–6) and similar ΔNIHSS% (−75%).ConclusionPatients with mRS 2 and 3 may benefit from rt-PA with a moderate risk of sICH and mortality.     

Feasibility and outcomes of intravenous thrombolysis 3–4.5 hours after stroke in Chinese patients

The time window for intravenous (IV) recombinant tissue plasminogen activator (rt-PA) treatment in acute ischemic stroke (AIS) patients has been extended to 4.5 hours. But little is known about the safety and efficacy of IV rt-PA treatment in the 3–4.5 hour time window in Chinese patients with AIS. A total of 119 patients who were treated with standard IV rt-PA therapy within 4.5 hours after symptom onset were included in this study: 85 were treated within 0–3 hours and 34 were treated within 3–4.5 hours. Favorable outcome was defined as a modified Rankin scale (mRS) score of 0–1 at 6 months. The safety of IV rt-PA treatment was assessed by the rate of mortality, symptomatic intracerebral hemorrhage (SICH) and other common complications. There were no significant differences in SICH rates (2.94% versus 2.35%; p = 0.85) at 24–36 hours, mortality (5.88% versus 3.53%; p = 0.56), other complications (14.71% versus 11.76%; p = 0.66), National Institutes of Health Stroke Scale (NIHSS) score improvement at 24 hours (41.18% versus 45.88%; p = 0.64) and favorable mRS at 6 months (52.94% versus 54.12%; p = 0.91) between the two time window groups. Multivariate analysis showed that advanced age, lower admission NIHSS score and shorter time from symptom onset to treatment were associated with a favorable clinical outcome. This finding showed an additional 29% of patients received IV rt-PA because of the treatment window expansion to 4.5 hours. IV rt-PA was feasible and safe for treating AIS patients in the 3–4.5 hour time window in our Chinese population.     

Direct access to a hospital offering intravenous thrombolysis therapy improves functional outcome of acute ischemic stroke patients

Referral from other hospitals is one of the primary causes of delayed thrombolysis therapy after acute ischemic stroke (AIS). We aimed to evaluate whether direct access to a hospital offering intravenous thrombolysis therapy was associated with good functional outcome in AIS patients treated with thrombolysis. We enrolled patients who received intravenous thrombolysis within 3 hours of symptom onset at our stroke center. We divided these patients into two groups: those with a direct admission to our stroke center and those with indirect admission by referral from other community hospitals. We investigated onset-to-door time and onset-to-recombinant tissue plasminogen activator (rtPA) time according to admission mode. We then assessed the association between a direct admission and favorable outcome at 90 days. A total of 232 patients (mean age of 66.6 years, median National Institutes of Health Stroke Scale score of 10) were included. A total of 48.7% of AIS patients treated with intravenous thrombolytic therapy were transferred from other hospitals. Patients who were directly admitted to our stroke center had a shorter onset-to-door time (61 versus 120 minutes, p < 0.001) and onset-to-rtPA time (103 versus 155 minutes, p < 0.001) than those referred from other hospitals. Direct admission was associated with a good outcome with an odds ratio of 2.03 (95% confidence interval 1.051–3.917, p = 0.035), after adjusting for baseline variables. Thrombolysis after direct admission to a hospital offering intravenous thrombolysis therapy could shorten onset-to-rtPA time and improve stroke outcome in patients with AIS.