动静脉联合溶栓治疗大脑中动脉闭塞引起的急性缺血性脑卒中

目的研究动静脉联合溶栓治疗大脑中动脉闭塞引起的急性缺血性脑卒中的安全性和有效性。方法回顾分析我院采用静脉溶栓或动静脉联合溶栓病例23例。卒中严重程度采用NIHSS评分评估,CTA,MRA或全脑血管造影评估再通情况,溶栓治疗后72 h内观察溶栓后非症状性和症状性出血,临床预后通过改良RS评分进行评估。结果静脉溶栓组14例,动静脉联合溶栓组9例,两组患者入院后NISS评分无统计学差异,动静脉联合溶栓后大脑中动脉再通率明显高于静脉溶栓组(77.8 vs.28.6%,P=0.036),而术后出现症状性及非症状性颅内出血与静脉溶栓比较无明显差异,90 d达到mRS 0-2分患者比例与静脉组比较无统计学差异,联合溶栓组高于静脉组。结论与静脉溶栓比较,应用动静脉联合溶栓治疗大脑中动脉闭塞引起的急性缺血性脑卒中是一种安全、有效的方法。     

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.     

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.     

Should IV Thrombolysis be given in Patients with Suspected Ischemic Stroke but Unknown Symptom Onset and Without Diffusion-Weighted Imaging Lesion? – Results of a Case-Control Study

BackgroundMany acute ischemic stroke (AIS) patients present with unknown time of symptom onset (UTO). In these situations, wake-up MRI protocols can guide treatment decisions: patients with DWI (diffusion-weighted imaging) but no fluid-attenuated inversion recovery lesion were shown to benefit from IVT (intravenous thrombolysis). However, initial MRI of some stroke patients is DWI negative, leaving it unclear whether this subgroup profits from IVT. Therefore, we aimed to compare the safety and efficacy of IVT in wake-up AIS patients with or without a DWI lesion in initial imaging.MethodsWe performed a case-control study. All AIS patients with UTO who underwent wake-up MRI and were treated with IVT at a German University Hospital from 2013 to 2017 were included. Patients without (DWI-) were compared to patients with DWI lesion (DWI+) regarding clinico-radiological characteristics, adverse events, and outcome at discharge. Likely stroke mimics were excluded.ResultsEleven DWI- and 32 DWI+ patients were included. There were no statistically significant differences regarding functional scores, age, sex, door-to-needle time, bleeding complications, and death. DWI+ patients more frequently had anterior circulation stroke (P = .049) and higher modified Rankin Scale (mRS) scores at discharge (P = .048). Solely in the DWI+ group 3 bleeding complications (2 asymptomatic hemorrhagic transformations, 1 muscle hematoma) and 3 deaths occurred (P = .29). A favourable outcome (mRS≤ 2) was achieved in 82% of the DWI- and in 58% of the DWI+ group (p > .05).ConclusionsOur data suggest that IVT may be used in DWI- patients with UTO with acute neurological symptoms very likely to be related to AIS.     

Intravenous thrombolysis in stroke patients with hyperdense middle cerebral artery sign

Background and purpose:  We assessed the safety and efficacy of intravenous thrombolysis (IVT) in acute stroke patients with hyperdense middle cerebral artery sign (HMCAS).
Patients and methods:  Data from consecutive patients with acute (within 6 h of symptom onset) ischaemic stroke admitted between January 1999 and November 2007, in whom HMCAS was diagnosed on admission CT scan was retrospectively analysed. Seventy-one patients, admitted within the 3-h window, were treated with IVT, whilst further 42, admitted 3–6 h after symptom onset, were not. At 3-month clinical follow-up, outcome, mortality at 3 months and incidence of symptomatic intracranial haemorrhage were evaluated.
Results:  The two groups were comparable concerning age, stroke risk factors, prior antithrombotic treatment and NIHSS scores on admission. Good outcome (mRS score ≤ 1) was observed in 12/71 (17%) patients who were treated with IVT and in 1/42 (2%) patients who were not ( P  = 0.02). IVT treatment was identified as independent predictor of good outcome ( P  = 0.05). Mortality was 20% in patients treated with IVT and 12% in remaining patients ( P  = 0.3). Symptomatic intracranial haemorrhage occurred in 1 patient of each group (2%).
Conclusions:  These findings suggest that IVT in patients with HMCAS results in significantly better outcome, without significantly influencing mortality.     

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。     

Is there a benefit of mechanical thrombectomy in patients with large stroke (DWI‐ASPECTS ≤ 5)?

Background and purpose

Whether to withhold mechanical thrombectomy when the diffusion‐weighted imaging (DWI) lesion exceeds a given volume is undetermined. Our aim was to identify markers that will help to select patients with large DWI lesions [DWI?Alberta Stroke Program Early Computed Tomography Score (DWI‐ASPECTS) ≤ 5] that may benefit from thrombectomy.

Methods

From May 2010 to November 2016, 82 acute ischaemic stroke patients with DWI‐ASPECTS ≤5 (43 men, 64.6 ± 14.4 years, National Institutes of Health Stroke Scale 18.4 ± 5.4) treated with state‐of‐the‐art mechanical thrombectomy were studied. Thrombectomy alone was performed in 28 (34%) and bridging therapy in 54 (66%) patients. Recanalization was defined as a thrombolysis in cerebral infarction score 2B‐3 and significant hemorrhagic transformation as parenchymal haematoma type 2 (European Cooperative Acute Stroke Study 3 classification). Pretreatment variables were compared between patients with a good (modified Rankin Scale 0?2) and a poor (modified Rankin Scale 3?6) neurological outcome at 3 months.

Results

Overall, 28 patients (34%) achieved good neurological outcome at 3 months. Recanalizers were significantly more likely to achieve good outcome (61% vs. 7.3%, P < 0.0001), had lower mortality (24% vs. 49%, P = 0.03) and similar rates of parenchymal haematoma type 2 (9.8% vs. 7.3%, P = 1) compared to non‐recanalizers. Regression modelling identified DWI‐ASPECTS >2 [odds ratio (OR) 6.93; 95% confidence interval (CI) 1.05–45.76, P = 0.04), glycaemia ≤6.8 mmol/l (OR 4.05; 95% CI 1.09–15.0, P = 0.03) and thrombolysis (OR 3.67; 95% CI 1.04–12.9, P = 0.04) as independent predictors of good neurological outcome.

Conclusions

In patients with DWI‐ASPECTS ≤5, two‐thirds of patients experienced good neurological outcome when recanalized by state‐of‐the‐art thrombectomy, whilst only one in 14 non‐recanalizers achieved similar outcomes. Pretreatment markers of good neurological outcomes were DWI‐ASPECTS >2, intravenous thrombolysis and glycaemia ≤6.8 mmol/l.     

Is atrial fibrillation associated with poor outcome after thrombolysis?

Atrial fibrillation (AF) is considered a predictor for severe stroke and poor outcome. The aim was to evaluate whether AF is associated with poor outcome in acute ischemic stroke (IS) patients treated with intravenous thrombolysis (IVT). In a retrospective study, 157 consecutive IS patients (98 males, mean age 67.3 ± 10.2 years), treated with IVT within 3 hours from stroke onset, were divided into two groups according to presence/absence of AF. Neurological deficit was evaluated using the NIHSS on admission, 24 hours, and 7 days later, while the 90-day clinical outcome was assessed using the modified Rankin Scale (mRS). A total of 66 patients (38 males) presented with AF. The baseline NIHSS was 13.3 ± 5.4 in AF and 11.0 ± 5.1 points in non-AF patients (P = 0.006). AF patients had arterial occlusions more frequently in the baseline MRA (54.5% in AF versus 25.3% in non-AF, P = 0.0002). No differences were found between groups in clinical improvement after 24 hours and 7 days or in rate of achieved recanalizations. AF patients had significantly poorer 90-day clinical outcome than non-AF patients (median mRS 2.5 vs. 1.0). Patients with AF had significantly worse 90-day clinical outcome after IVT compared to those without AF, probably due to more severe baseline neurological deficits and the greater number of arterial occlusions in the MRA before IVT.     

Predictors of dependence after MCA ischemic stroke submitted to thrombolysis

Objectives: Stroke is one of the most common causes of disability-adjusted life years worldwide. The aim of this study is to identify variables associated with dependence at 3 months and also after the first 3 months after the first-ever ischemic stroke (IS) in middle cerebral artery (MCA) territory submitted to intravenous thrombolysis (IVT).

Methods: A single-center cohort study of patients with first-ever MCA IS treated with IVT at the Hospital de Clínicas, Universidade Federal do Paraná, was followed over 5 years. Logistic regression was performed to determine predictors of early and late dependence.

Results: A total of 144 patients were included; 48.6% women, and 47.2% were dependent at 3 months after stroke. NIHSS at admission (OR = 1.3, 95%CI = 1.16–1.45, p < 0.001), large artery atherosclerosis (LAA) stroke (OR = 4.11, 95%CI = 1.31–12.85, p = 0.014) and pneumonia during hospitalization (OR = 9.17, 95%CI = 1.42–59.07, p = 0.019) were predictors for early dependence. For the late dependence analyses, 99 patients were included; 49.5% women and 39.4% were dependent after 3 months of stroke. NIHSS at admission (OR = 1.33, 95%CI = 1.15–1.54, p < 0.001), pneumonia during hospitalization (OR = 11.08, 95%CI = 1.45–84.73, p = 0.019) and seizure after discharge (OR = 5.82, 95%CI = 1.06–32.01, p = 0.040) were predictors for late dependence.

Discussion: .Dependence is an important indicator of the efficacy of stroke care. Besides it was not possible to evaluate rehabilitation, this is the first study on predictors of post-stroke dependence that focus exclusively on patients with first-ever MCA IS submitted to IVT. NIHSS, LAA stroke, in-hospital pneumonia and seizures after discharge were associated with dependence after first-ever MCA IS submitted to IVT.     

Increasing use of intravenous rt–PA does not affect safety in acute stroke

Background Intravenous thrombolysis with rt–PA improves outcome in acute ischemic stroke. In a prospective study we analyzed the annual frequency of rt–PA treatment, its safety, and early clinical outcome. Methods All patients admitted to our stroke unit (SU) from 1998 to 2003 were registered in a prospective data base. Documented data included patient age, sex, time interval until admission, initial therapy (e. g., thrombolysis), death, intracerebral hemorrhage, other complications, and score on the National Institute of Health Stroke Scale (NIHSS). Results From 1998 to 2003, a total of 112 patients were treated with systemic thrombolysis. The number of acute stroke patients admitted within 2.5 hours and therefore eligible for thrombolysis did not substantially change between 1998 and 2003. From 1998 to 2001 the percentage of acute stroke patients that received rt–PA was stable (12.6–16.9 %). This percentage increased in 2002 (29.6%, p<0.05) and, again, in 2003 (42.1%, p<0.01). Of all treated patients, two developed symptomatic intracerebral hemorrhage (1.8%) and five died three to seven days after thrombolysis (4.5 %). The NIHSS score of patients receiving rt–PA significantly decreased during the acute treatment phase (14.2±5.1 to 8.0±5.9, p<0.001). A comparison of single years revealed that this NIHSS score reduction was stable. Conclusion In our selected patients, the proportion of acute stroke patients treated with systemic thrombolysis increased almost three–fold from 1998 to 2003. This may be explained by protocol modifications and growing experience with the use of rt–PA. Our data demonstrate that increased use of rt–PA in acute stroke patients can be achieved without adversely affecting safety or clinical benefit.     

CT volume/density ratio as the marker of ischaemic brain injury

Kurzepa J, Bielewicz J, Czekajska‐Chehab E, Kurzepa J, Bartosik‐Psujek H, Grabarska A, Stelmasiak Z. CT volume/density ratio as the marker of ischaemic brain injury.
Acta Neurol Scand: 2011: 123: 310–315.
© 2010 John Wiley & Sons A/S. Objectives – We believe that the CT volume/density ratio (VDR) of infarcted area reflects the degree of brain tissue damage during ischaemic stroke (IS). Patients and methods – Forty six patients with IS were prospectively enrolled into the study. CT scan was performed on days 1 and 10 of hospitalization. S100BB serum level, gelatinase activities (MMP‐2 and MMP‐9) and neurological examination (NIHSS) were performed on days 1, 5 and 10 of IS. After 3 months, 42 patients were examined by functional disability scales: Barthel index (BI) and modified Rankin scale (mRS). Results – The VDR of ischaemic focus correlated well with the average S100BB serum level, MMP‐9 serum activity and NIHSS score. The weak but statistically significant relationships were noticed between the VDR vs BI and mRS estimated 3 months after stroke. Conclusion – VDR reflects well the damage ratio of brain tissue during IS. In addition, the study underlines the relationship between VDR vs patients’ neurological status and disability after IS.     

Stroke initial severity and outcome relative to insurance status in a universal health care system in Switzerland

Background: Socioeconomic status is thought to have a significant influence on stroke incidence, risk factors and outcome. Its influence on acute stroke severity, stroke mechanisms, and acute recanalisation treatment is less known. Methods: Over a 4‐year period, all ischaemic stroke patients admitted within 24 h were entered prospectively in a stroke registry. Data included insurance status, demographics, risk factors, time to hospital arrival, initial stroke severity (NIHSS), etiology, use of acute treatments, short‐term outcome (modified Rankin Scale, mRS). Private insured patients (PI) were compared with basic insured patients (BI). Results: Of 1062 consecutive acute ischaemic stroke patients, 203 had PI and 859 had BI. They were 585 men and 477 women. Both populations were similar in age, cardiovascular risk factors and preventive medications. The onset to admission time, thrombolysis rate, and stroke etiology according to TOAST classification were not different between PI and BI. Mean NIHSS at admission was significantly higher for BI. Good outcome (mRS ≤ 2) at 7 days and 3 months was more frequent in PI than in BI. Conclusion: We found better outcome and lesser stroke severity on admission in patients with higher socioeconomic status in an acute stroke population. The reason for milder strokes in patients with better socioeconomic status in a universal health care system needs to be explained.     

Endovascular thrombectomy for basilar artery occlusion stroke: Analysis of the German Stroke Registry-Endovascular Treatment

Background and purpose

Acute ischemic stroke due to basilar artery occlusion (BAO) causes the most severe strokes and has a poor prognosis. Data regarding efficacy of endovascular thrombectomy in BAO are sparse. Therefore, in this study, we performed an analysis of the therapy of patients with BAO in routine clinical practice.

Methods

Patients enrolled between June 2015 and December 2019 in the German Stroke Registry-Endovascular Treatment (GSR-ET) were analyzed. Primary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3), substantial neurological improvement (≥8-point National Institute of Health Stroke Scale [NIHSS] score reduction from admission to discharge or NIHSS score at discharge ≤1), and good functional outcome at 3 months (modified Rankin Scale [mRS] score of 0–2).

Results

Out of 6635 GSR-ET patients, 640 (9.6%) patients (age 72.2 ± 13.3, 43.3% female) experienced BAO (median [interquartile range] NIHSS score 17 [8, 27]). Successful reperfusion was achieved in 88.4%. Substantial neurological improvement at discharge was reached by 45.5%. At 3-month follow-up, good clinical outcome was observed in 31.1% of patients and the mortality rate was 39.2%. Analysis of mTICI3 versus mTICI2b groups showed considerable better outcome in those with mTICI3 (38.9% vs. 24.4%; p = 0.005). The strongest predictors of good functional outcome were intravenous thrombolysis (IVT) treatment (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.76–5.23) and successful reperfusion (OR 4.92, 95% CI 1.15–21.11), while the effect of time between symptom onset and reperfusion seemed to be small.

Conclusions

Acute reperfusion strategies in BAO are common in daily practice and can achieve good rates of successful reperfusion, neurological improvement and good functional outcome. Our data suggest that, in addition to IVT treatment, successful and, in particular, complete reperfusion (mTICI3) strongly predicts good outcome, while time from symptom onset seemed to have a lower impact.     

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.     

Thrombolysis in patients with acute stroke caused by cervical artery dissection: analysis of 9 patients and review of the literature

BACKGROUND: Results of recently published studies suggest that intravenous thrombolysis (IVT) and local intra-arterial thrombolysis (LIT) are feasible procedures in acute stroke after cervical artery dissection (CAD). OBJECTIVES: To describe 9 patients with acute stroke caused by CAD who were treated by LIT (n = 7) or IVT (n = 2) and to review the literature. METHODS: Retrospective analysis of clinical and neuroradiological findings; literature review from 1980 to present. MAIN OUTCOME MEASURE: Modified Rankin Scale (mRS) score. RESULTS: Of 7 patients treated with LIT, 3 had good outcomes (mRS score of 0-2) and 4 had bad outcomes (mRS score of 3-6) at 3 months. The 2 patients who had received IVT recovered to mRS scores of 0 and 3. Twenty-one patients were identified in the literature. Overall (N = 30), in the IVT group (n = 19), the outcome was good in 8 patients (42%) and bad in 11 (58%); in the LIT group (n = 11), 6 patients (55%) had a good outcome and 5 (45%) had a bad outcome. Overall, 47% (14/30) of the patients (IVT and LIT groups) had a good outcome. Total mortality was 13% (4/30). There were no secondary complications due to extension of wall hematoma or angiography. One symptomatic hemorrhage occurred. CONCLUSIONS: Thrombolysis is feasible in acute stroke caused by CAD. Local complications from extension of wall hematoma did not occur. Further prospective studies are needed to determine the safety and efficacy of thrombolysis in the special circumstance of acute stroke caused by CAD.     

颈内动脉系统脑梗死3～6 h静脉溶栓与动脉溶栓的比较

目的 观察颈内动脉系统梗死患者3～6 h时间窗内静脉溶栓和动脉溶栓治疗的疗效.方法 对34例发病3～4.5 h和18例发病4.5～6 h颈内动脉系统梗死患者,根据头颅磁共振灌注加权成像(PWI)/弥散加权成像(DWI)≥20%,分别行静脉和动脉内超选择性重组组织型纤溶酶原激活剂(rt-PA)溶栓治疗.治疗前后进行卒中量表(NIHSS)评分,并观察血管再通率、出血率,治疗后90 d用修正Raikin量表(MRS)评价临床预后.结果 溶栓后2组患者NIHSS评分较治疗前明显改善(P＜0.05),2组间NIHSS的改善程度差异无统计学意义(P＞0.05).治疗后90 d预后良好率:静脉溶栓组55.9%,动脉溶栓组61.1%,2组间比较差异无统计学意义(P＞0.05).血管再通率:静脉溶栓组47.1%、动脉溶栓组77.8%,2组间比较差异有统计学意义(P＜0.05).出血率:静脉溶栓组17.6%,动脉溶栓组33.3%,2组比较差异无统计学意义(P＞0.05).结论 在头颅MR PWI/DWI不匹配时,颈内动脉系统脑梗死发生3~4.5 h内静脉溶栓与4.5~6 h内动脉溶栓治疗安全有效,两者的效果相当.     

Influence of pretreatment MRI parameters on clinical outcome, recanalization and infarct size in 49 stroke patients treated by intravenous tissue plasminogen activator

We hypothesized that pretreatment magnetic resonance imaging (MRI) parameters might predict clinical outcome, recanalization and final infarct size in acute ischemic stroke patients treated by intravenous recombinant tissue plasminogen activator (rt-PA). MRI was performed prior to thrombolysis and at day 1 with the following sequences: magnetic resonance angiography (MRA), T2*-gradient echo (GE) imaging, diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI). Final infarct size was assessed at day 60 by T2-weighted imaging (T2-WI). The National Institutes of Health Stroke Scale (NIHSS) score was assessed prior to rt-PA therapy and the modified Rankin Scale (m-RS) score was assessed at day 60. A poor outcome was defined as a day 60 m-RS score >2. Univariate and multivariate logistic regression analyses were used to identify the predictors of clinical outcome, recanalization and infarct size. Forty-nine patients fulfilled the inclusion criteria. Baseline NIHSS score was the best independent indicator of clinical outcome (p=0.002). A worse clinical outcome was observed in patients with tandem internal carotid artery (ICA)+middle cerebral artery (MCA) occlusion versus other sites of arterial occlusion (p=0.009), and in patients with larger pretreatment PWI (p=0.001) and DWI (p=0.01) lesion volumes. Two factors predict a low rate of recanalization: a proximal site of arterial occlusion (p=0.02) and a delayed time to peak (TTP) on pretreatment PWI (p=0.05). The final infarct size was correlated with pretreatment DWI lesion volume (p=0.025). Recanalization was associated with a lower final infarct size (p=0.003). In conclusion, a severe baseline NIHSS score, a critical level of pretreatment DWI/PWI parameters and a proximal site of occlusion are predictive of a worse outcome after IV rt-PA for acute ischemic stroke.     

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.     

Serum adiponectin acutely after an ischemic stroke: implications for a long‐lasting,suppressed anti‐inflammatory role

Marousi S, Theodorou G, Karakantza M, Papathanasopoulos P, Ellul J. Serum adiponectin acutely after an ischemic stroke: implications for a long‐lasting, suppressed anti‐inflammatory role.
Acta Neurol Scand: 2010: 121: 277–284.
© 2009 The Authors Journal compilation © 2009 Blackwell Munksgaard. Objective – Past ischemic stroke (IS) patients display suppressed adiponectin (ADPN) levels a few months after disease onset. It is still unclear whether hypoadiponectinemia is already present by the early stages of stroke or occurs as a delayed effect of the acute ischemic reaction. In the present study we investigated ADPN levels acutely after an IS. Materials and methods – Serum ADPN was measured in 82 consecutive acute IS patients, and 30 stroke‐free subjects of similar age and sex distributions. Results – Patients had significantly lower ADPN levels than controls. Higher ADPN was significantly associated with reduced odds for IS accounting for age, sex and high‐density lipoproteins. This association was strengthened after further adjustments for potential confounders. ADPN levels remained suppressed even 6 months after stroke. Conclusions – ADPN is significantly suppressed already by the early phases of stroke, and remains unchanged 6 months later. We propose a stable‐over‐time anti‐inflammatory role of ADPN in IS, unrelated to the acute ischemic reaction.     

Survival over 12 years following acute stroke: initial treatment in a stroke unit vs general medical wards

Stavem K, Rønning OM. Survival over 12 years following acute stroke: initial treatment in a stroke unit vs general medical wards.
Acta Neurol Scand: 2011: 124: 429–433.
© 2011 John Wiley & Sons A/S. Background – Few studies have assessed the influence of the organization of stroke care on long‐term survival. Aims of the study – To compare survival over 12 years after stroke between subjects treated in an acute stroke unit (SU) and those treated in general medical wards (GMW). Methods – In total, 550 subjects ≥60 years of age with acute stroke were prospectively allocated according to date of birth (day of the month) to treatment in a SU with relatively short length of stay or GMWs. We assessed survival through a link to the register of Statistics Norway. Groups were compared using Kaplan–Meier analysis on an intention‐to‐treat basis. Results – Of the 550 eligible subjects, 271 were allocated to a SU and 279 to GMWs. There still was no difference in mortality over 12 years between the groups (P = 0.15, log‐rank test) Conclusions – An acute SU offering early treatment and rehabilitation did not offer better long‐term mortality after stroke in patients ≥60 years old than initial treatment in GMWs.