A Critical Analysis of Intra-arterial Thrombolytic Doses in Acute Ischemic Stroke Treatment

Background

Intra-arterial thrombolytics (IAT) such as Alteplase, Tenecteplase, and Reteplase are currently used in patients with acute ischemic stroke in varying doses. We evaluated the relationship of IA thrombolytic dose with angiographic recanalization, intracerebral hemorrhage (ICH) rates, and clinical outcomes at three comprehensive stroke centers.

Methods

We stratified patients who underwent endovascular treatment into tertiles based on intra-arterial thrombolytic dose administered: lower tertile (range 1.5–5 mg), middle tertile (range 6–10 mg), and upper tertile (range 10.3–68.5 mg) of rt-PA equivalent. The rates of angiographic recanalization, ICH, and favorable clinical outcomes (discharge modified Rankin score [mRS] = 0–2) were ascertained and compared within the three tertiles. Logistic regression analyses were performed to determine the association between IA thrombolytic dosages and angiographic recanalization, ICH, and favorable clinical outcomes after adjusting for potential confounders.

Results

A total of 197 patients were treated with IAT; mean age ±SD was 65.6 ± 16 years; 105 (53.3 %) were women. Ninety-one (46.2 %) patients received both IVT and IAT. IA rt-PA equivalent dose was not different between the patients with and without ICH [mean (mg) ± SD, 9.8 ± 6.1 versus 9.8 ± 9.5, p = 0.9]. We did not find any relation between increasing doses of IAT (from 2 to 69 mg rt-PA equivalent) and symptomatic or asymptomatic ICH: (p = 0.1630) and (p = 0.6702), respectively. Multivariate analysis demonstrated that IAT dose was not associated with ICH (OR 1.0, 95 % CI 0.97–1.07, p = 0.3919) or favorable outcome (OR, 1.00, 95 % CI 0.95–1.06, p = 0.7375). In a subset analysis of IVT patients, total doses ranged from 48.2 to 149 mg and were not associated with either symptomatic (p = 0.23) or asymptomatic (p = 0.24) ICHs.

Conclusion

Our study demonstrates that IAT in doses up to 69 mg is safe without any evidence of dose-related ICHs even in those patients who had received IVT.     

Multimodal Therapy for Patients with Acute Ischemic Stroke : Outcomes and Related Prognostic Factors

Objective

The objectives of this study were to analyze the recanalization rates and outcomes of multimodal therapy that consisted of sequential intravenous (IV)/intra-arterial (IA) thrombolysis, mechanical thrombolysis including mechanical clot disruption using microcatheters and microwires, balloon angioplasty, and stenting for acute ischemic stroke, and to evaluate the prognostic factors related to the outcome.

Methods

Fifty patients who were admitted to the hospital within 8 hours from ischemic symptom onset were retrospectively analyzed. Initial IV thrombolysis and subsequent cerebral angiography were performed in all patients. If successful recanalization was not achieved by IV thrombolysis, additional IA thrombolysis with mechanical thrombolysis, including balloon angioplasty and stenting, were performed. The outcomes were assessed by the National Institute of Health Stroke Scale (NIHSS) change and modified Rankin scale (mRS) and prognostic factors were analyzed.

Results

Successful recanalization was achieved in 42 (84%) of 50 patients, which consisted of 8 patients after IV thrombolysis, 19 patients after IA thrombolysis with mechanical clot disruption, and 15 patients after balloon angioplasty or stenting. Symptomatic hemorrhage occurred in 4 (8%) patients. Good outcomes were achieved in 76% and 70% of patients upon discharge, and 93% and 84% of patients after 3 months according to the NIHSS change and mRS. The initial clinical status, recanalization achievement, and presence of symptomatic hemorrhage were statistically related to the outcomes.

Conclusion

Multimodal therapy may be an effective and safe treatment modality for acute ischemic stroke. Balloon angioplasty and stenting is effective for acute thrombolysis, and produce higher recanalization rates with better outcomes.     

Systemische Thrombolysetherapie des akuten Hirninfarkts

Background

About 1,300 stroke patients from a primarily rural area are treated each year at the Department of Neurology of the University Hospital of Heidelberg, Germany. Demographic and treatment data of all stroke patients there were prospectively collected. In a retrospective study we report on the changes in this patient population from 1996 to 2006, with special consideration of those suitable for intravenous thrombolysis.

Methods

For all stroke patients the basic data were collected—age, sex, type of stroke (transient ischemic attack, stroke, or intracerebral hemorrhage), NIH Stroke Scale, duration between symptom onset and hospital arrival, delay between arrival and first doctor’s contact, patient’s further whereabouts, and for patients treated by iv thrombolysis, start of treatment and dosage.

Results

There were no changes in the total number of stroke patients and median stroke severity, according to the NIH Stroke Scale, from 1996 to 2006. The proportion of stroke patients admitted within the first 3 h after symptom onset increased from 12.1% (1996) to 21.9% (2006). Thus we managed to treat 10.1% of all our ischemic stroke patients with iv thrombolysis, which means 39% of those patients with cerebral infarction arriving within 3 h.

Discussion

During the study period there were no significant changes in the patients’ sociodemographic data. By consistent reduction of prehospital delay, the number of stroke patients that could be treated acutely by intravenous thrombolysis was increased.     

Fast-Track Intubation for Accelerated Interventional Stroke Treatment

Background

As intravenous thrombolysis frequently fails to recanalize occluded proximal intracerebral arteries, interventional recanalization therapy is increasingly being considered as treatment option in acute ischemic stroke patients. The optimal periprocedural patient management for these interventions is currently unknown. The aim of this study was to identify factors delaying door-to-treatment times, and to evaluate the effect of a fast-track intubation standard operating procedure (I-SOP) on door-to-angiography time.

Methods

First, we retrospectively reviewed records of 48 acute stroke patients who were treated by interventional recanalization of intracranial occlusions between 2006 and 2009 at our institution. Time to angiography was defined as time from hospital admission to the beginning of the angiographic procedure. Second, an I-SOP for fast-track intubation was implemented and effects on door-to-angiography time were prospectively analyzed in 23 consecutive patients.

Results

In the retrospective dataset (n?=?48), the mean door-to-angiography time was 2.2?±?0.1?h (mean?±?SEM). A clinically relevant time loss attributable to the intubation procedure was suggested by a 51?±?21?min shorter door-to-angiography time for patients already intubated prior to admission (P?=?0.0189). Additional factors associated with a prolonged door-to-angiography time were: door-to-diagnosis time (P?<?0.001), onset-to-door time (P?=?0.0117), and male gender (mean difference +27?±?15?min, P?=?0.0822). In the prospective dataset (n?=?23), I-SOP implementation reduced mean door-to-angiography time by 25?±?10?min (P?=?0.0164).

Conclusions

In acute stroke patients, intubation prior to interventional recanalization therapy can delay treatment initiation. The implementation of an I-SOP accelerates interventional treatment initiation.     

Thrombectomy for Acute Ischemic Stroke: Recent Insights and Future Directions

Purpose of Review

Mechanical thrombectomy has become the standard of care for acute ischemic stroke with proximal large vessel occlusions (LVO). This article reviews recent research relating to thrombectomy.

Recent Findings

Thrombectomy for anterior circulation stroke with proximal LVO was first shown to be highly efficacious within 6 h of stroke onset, but “late-window” trials have further demonstrated efficacy until 24-h postonset in select patients with salvageable tissue. However, the concept of “time is brain” remains critical. Thrombectomy trials have further stimulated worldwide efforts to develop systems of care for rapid treatment of eligible patients. Thrombectomy is cost-effective and likely to have long-term efficacy for both disability and mortality outcomes.

Summary

Thrombectomy is a highly efficacious acute stroke therapy. Enduring uncertainties include efficacy in patients with premorbid disability, posterior circulation, or more distal occlusions; use of bridging thrombolysis; and optimal techniques to achieve consistent revascularization and address tandem occlusions or stenoses.

     

Comparison of Mechanical Embolectomy and Intraarterial Thrombolysis in Acute Ischemic Stroke within the MCA: MERCI and Multi MERCI compared to PROACT II

Introduction  Intraarterial thrombolysis and mechanical embolectomy have been studied for endovascular treatment of stroke. The MERCI and Multi MERCI trials of mechanical embolectomy with or without adjuvant intraarterial thrombolysis demonstrated effective recanalization, but with a higher mortality compared with control patients in the PROACT II trial of intraarterial thrombolysis. Differences in trial design may account for this mortality difference. Methods  We identified patients in the MERCI and Multi MERCI trials who would have been eligible for PROACT II. Rates of good outcome (mRS ≤2) and mortality at 90 days were compared, adjusting for differences in baseline NIHSS score and age. Results  Sixty-eight patients enrolled in MERCI and 81 enrolled in Multi MERCI were eligible for PROACT II. In both unadjusted and adjusted analyses, PROACT II-eligible embolectomy patients showed a trend toward better clinical outcomes compared to the PROACT II control arm (adjusted, MERCI 35.4% [p = ns], Multi MERCI 42.8% [p = 0.048], PROACT II control, 25.4%). In both unadjusted and adjusted analyses, mortality rates did not significantly differ between embolectomy patients and PROACT II control patients (adjusted analysis, MERCI 29.1%, Multi MERCI 18.0%, PROACT II control, 27.1%). Compared with the PROACT II treatment group, embolectomy groups showed similar rates of good outcome and mortality. Conclusions  Differences in mortality and proportion of good outcome between the MERCI/Multi MERCI trials and the PROACT II trial are explained by differences in study design and baseline characteristics of patients. Mechanical embolectomy and IA thrombolysis may each be reasonable strategies for acute stroke; a randomized trial is necessary to confirm these results.     

Outcomes in Severe Middle Cerebral Artery Ischemic Stroke

Background

Severe middle cerebral artery stroke (MCA) is associated with a high rate of morbidity and mortality. We assessed the hypothesis that patient-specific variables may be associated with outcomes. We also sought to describe under-recognized patient-centered outcomes.

Methods

A consecutive, multi-institution, retrospective cohort of adult patients (≤70 years) was established from 2009 to 2011. We included patients with NIHSS score ≥15 and infarct volume ≥60 mL measured within 48 h of symptom onset. Malignant edema was defined as the development of midline brain shift of ≥5 mm in the first 5 days. Exclusion criterion was enrollment in any experimental trial. A univariate and multivariate logistic regression analysis was performed to model and predict the factors related to outcomes.

Results

46 patients (29 female, 17 male; mean age 57.3 ± 1.5 years) met study criteria. The mortality rate was 28 % (n = 13). In a multivariate analysis, only concurrent anterior cerebral artery (ACA) involvement was associated with mortality (OR 9.78, 95 % CI 1.15, 82.8, p = 0.04). In the malignant edema subgroup (n = 23, 58 %), 4 died (17 %), 7 underwent decompressive craniectomy (30 %), 7 underwent tracheostomy (30 %), and 15 underwent gastrostomy (65 %).

Conclusions

Adverse outcomes after severe stroke are common. Concurrent ACA involvement predicts mortality in severe MCA stroke. It is useful to understand the incidence of life-sustaining procedures, such as tracheostomy and gastrostomy, as well as factors that contribute to their necessity.     

Endovascular treatment of acute carotid occlusion

Objectives

Acute cervical carotid occlusion is one of the most challenging scenarios encountered in endovascular stroke treatment.

Patients and methods

A retrospective analysis of 11 consecutive non-dissection stroke patients with concomitant cervical carotid and intracranial occlusion treated with intraarterial (IA) mechanical thrombectomy and/or pharmacologic thrombolysis over five years at two academic hospitals was performed. Data was analyzed using Fisher's exact test.

Results

Patients included 3 females and 8 males. Average age was 64.7 years (range 30–94 years). All patients had both cervical carotid and intracranial occlusions. Intracranial occlusion involved the internal carotid artery in 7 patients and the middle cerebral artery in 4 patients. All of the patients received intracranial IA Tissue Plasminogen Activator (tPA). Six patients received carotid stents for cervical occlusion as part of their treatment. Five patients received only IA tPA via collateral circulation.Of the patients receiving stents, 5 of 6 (83.3%) had successful recanalization (Thrombolysis in Cerebral Ischemia 2b or 3 flow). Only 1 of 5 (20%) patients who did not receive stents prior to intracranial treatment had successful recanalization. The difference in recanalization rates approached statistical significance (p = .08). There were 4 total in-hospital mortalities: 2 in the group that received stents prior to thrombolysis and 2 in the non-stent group. There were 2 clinically significant hemorrhages in the study, both in the stent group.

Conclusions

Revascularization of the cervical carotid occlusion prior to treatment of the intracranial occlusion led to increased rates of recanalization in patients with tandem extracranial and intracranial occlusions. Whether a clinical benefit can be consistently derived likely relies on other factors, including the evaluation of cerebral perfusion.     

Prolonged Low-Dose Thrombolysis in Posterior Circulation Stroke

Background

We aimed to investigate the feasibility, preliminary safety, and efficacy of prolonged low-dose intravenous thrombolysis in posterior circulation stroke patients with a thrombus lodged in the basilar artery who were ineligible for standard rtPA administration.

Methods

We retrospectively analyzed consecutively collected patients in our stroke database who suffered from a basilar artery thrombosis and were treated with prolonged (>1 h), intravenous, low-dose (≤20 mg) rtPA between 01/2005 and 11/2012.

Results

Patients included in this study (n = 14) were 68.5 years (IQR 55.5; 72.75) of age and presented with a median NIHSS of 2 (1; 5.25). Median time from symptom onset to treatment was 63 h (33; 141). A median dose of 5.21 μg/kg h (4.46; 6.25) rtPA was administered over 24 h (min 10; max 48). No patient experienced symptomatic intracerebral hemorrhage, one patient developed a spinal epidural hematoma, and two elderly patients were switched to comfort care and died. In eight patients (57 %) a decrease in thrombus size or no thrombus at all was detected on control imaging. Nine patients (64 %) had a favorable outcome (mRS 0–2) at day 90.

Conclusions

Prolonged low-dose thrombolysis with rtPA may be considered as individual treatment option in selected high-risk patients with basilar artery thrombosis. Presented data may lay the groundwork to further investigate safety and efficacy in a prospective trial.     

Long-Term Outcomes of Post-Thrombolytic Intracerebral Hemorrhage in Ischemic Stroke Patients

Background

Intracerebral hemorrhage (ICH) is an infrequent complication of intravenous recombinant tissue plasminogen activator (rt-PA) for the treatment of acute stroke. However, such ICH is an important reason for withdrawal of care because of lack of adequate data regarding long-term patient outcomes.

Objective

To report the long-term outcomes in patients with post-thrombolytic ICH.

Methods

We analyzed patient data from a randomized, placebo-controlled trial in patients with ischemic stroke presenting within 3 h of symptom onset. Baseline clinical characteristics and outcomes defined by modified Rankin scale (mRS) were ascertained at 3, 6, and 12 months after treatment in patients who suffered from post-thrombolytic ICH. Favorable outcome was defined by mRS of 0–3 and unfavorable outcome by mRS of 4–6 at 1 year.

Results

A total of 48 patients suffered post-thrombolytic ICH in the trial. Fourteen patients had favorable outcomes and 34 patients had unfavorable outcomes. Clinical characteristics did not have an impact on patient outcomes at 12 months. Patients with unfavorable outcomes were more likely to have an National Institutes of Health Stroke Scale (NIHSS) score ≥20 at 7–10 days after treatment (64 vs. 7 %, p < 0.0009). Patients with unfavorable outcomes were more likely to have a worsening of NIHSS score of >4 points at 7–10 days from their baseline NIHSS (44 vs. 0 %, p = 0.0006).

Conclusion

Approximately 30 % of patients with post-thrombolytic ICH have favorable outcomes at 1 year which does not support early withdrawal of care. Ascertainment of NIHSS score and worsening of NIHSS score at 7–10 days may be necessary for accurate prognostic stratification.     

Qualitätsparameter der akuten Schlaganfallversorgung

Background

The long-term prognosis of stroke patients is still dependent in particular on the timing of a correct diagnosis, immediate initiation of a suitable specific therapy and competent treatment in a stroke unit. Therefore, nationwide attempts are being made to establish a comprehensive coverage of the necessary specific competence and infrastructural requirements. Divergent regional circumstances and economic viewpoints determine the characteristics of the various healthcare concepts and the interplay between participating cooperation partners. This article compares the development with respect to three qualitative treatment parameters exemplified by four regional healthcare models during the time period 2008–2011.

Methods

The hospitalization rates for patients with transitory ischemic attacks, ischemic and hemorrhagic stroke, the case numbers for stoke unit treatment and the rates of systemic thrombolysis and mechanical thrombectomy in the regions of Berlin, the Ruhr Area, Ostwestfalen-Lippe and southeast Bayern (TEMPiS) are presented based on the data from the DRG statistical reports for the years 2008 and 2011.

Results

The average hospitalization rates for ischemic stroke patients (brain infarct ICD 163) in the time period from 2008 to 2011 were 294 per 100,000 inhabitants for the Ruhr Area, 257 per 100,000 inhabitants for Ostwestfalen-Lippe and 265 per 100,000 inhabitants each for Berlin and southeast Bayern. The complex stroke treatment quota for southeast Bayern in 2008 was 31 % and 47 % in 2011 and the respective quotas for the other regions studied were 42–44 % and 58–59 %. The rate of systemic thrombolysis in 2008 ranged between 4.2 % and 7.4 % and in 2011 the increase in the range for the 4 regions studied was between 41 % and 145 %. In 2011 the thrombectomy quota of 2 % in the Ruhr Area was the only one which was above the national average of 1.3 % of all brain infarcts.

Discussion

Stroke is a common disease in the four regions studied. For the established forms of therapy, complex treatment of stroke and systemic thrombolysis, the positive effect of structurally improved approaches in the four different regional treatment concepts could be confirmed during the course of the observational time period selected. Mechanical thrombectomy which is currently still considered to be an individual healing attempt, was used significantly more often in the Ruhr Area in 2011 than in the other three regions studied. A standardized referral procedure had previously been established in the metropolitan regions.     

Association of Intraprocedural Blood Pressure and End Tidal Carbon Dioxide with Outcome After Acute Stroke Intervention

Background

General anesthesia (GA) for acute stroke interventions may be associated with inferior functional outcomes. Our goal was to identify physiologic parameters that mediate this association.

Methods

Consecutive patients treated at our institution between August 2007 and December 2010 were identified from a prospective database. Clinical data were then extracted by retrospective chart review. Variables significantly associated with outcome in univariate analysis were also examined in multivariate analysis, controlling for well-established prespecified predictors of functional outcome.

Results

Of the 106 patients identified, 20 were excluded (17 due to the absence of 90-day mRS and 3 due to insufficient anesthetic records). Blood pressure (BP) decreased significantly after induction of GA, but there was no association between BP and outcome. End tidal carbon dioxide values (ETCO2) at 60 and 90 min, however, were significantly associated with outcomes in both univariate and multivariate analyses. Mean ETCO2 in patients with favorable outcomes (modified Rankin Scale (mRS) 0–3) was higher than in those with unfavorable outcomes (mRS 4–6): 35.2 mmHg versus 32.2 (p = 0.03) at 60 min and 34.9 versus 31.9 (p = 0.04) at 90 min. The adjusted odds ratios for poor outcomes for each 1 mmHg decrease in ETCO2 were the same: 0.76 (95 % CI 0.65–0.92; p = 0.004) at 60 min and 0.76 (95 % CI 0.61–0.93; p = 0.01) at 90 min.

Conclusions

While BP decreased significantly in patients undergoing GA for acute stroke intervention, it did not correlate with patient outcome. Decreases in ETCO2 at 30 and 60 min, however, were associated with 90-day mRS.     

Intravenous thrombolysis for ischemic stroke in the golden hour: propensity-matched analysis from the SITS-EAST registry

As there are scarce data regarding the outcomes of acute ischemic stroke (AIS) patients treated with intravenous thrombolysis (IVT) within 60 min from symptom onset (“golden hour”), we sought to compare outcomes between AIS patients treated within [GH(+)] and outside [GH(?)] the “golden hour” by analyzing propensity score matched data from the SITS-EAST registry. Clinical recovery (CR) at 2 and 24 h was defined as a reduction of ≥10 points on NIHSS-score or a total NIHSS-score of ≤3 at 2 and 24 h, respectively. A relative reduction in NIHSS-score of ≥40% at 2 h was considered predictive of complete recanalization (CREC). Symptomatic intracranial hemorrhage (sICH) was defined using SITS-MOST criteria. Favorable functional outcome (FFO) was defined as a mRS-score of 0–1 at 3 months. Out of 19,077 IVT-treated AIS patients, 71 GH(+) patients were matched to 6882 GH(?) patients, with no differences in baseline characteristics (p > 0.1). GH(+) had higher rates of CR at 2 (31.0 vs. 12.4%; p < 0.001) and 24 h (41 vs. 27%; p = 0.010), CREC at 2 h (39 vs. 21%; p < 0.001) and FFO (46.5 vs. 34.0%; p = 0.028) at 3 months. The rates of sICH and 3-month mortality did not differ (p > 0.2) between the two groups. GH(+) was associated with 2-h CR (OR: 5.34; 95% CI 2.53–11.03) and CREC (OR: 2.38; 95% CI 1.38–4.09), 24-h CR (OR: 1.88; 95% CI 1.08–3.26) and 3-month FFO (OR: 2.02; 95% CI 1.15–3.54) in multivariable logistic regression models adjusting for potential confounders. In conclusion, AIS treated with IVT within the GH seems to have substantially higher odds of early neurological recovery, CREC, 3-month FFO and functional improvement.     

Bone Flap Necrosis After Decompressive Hemicraniectomy for Malignant Middle Cerebral Artery Infarction

Background

Autologous bone flap reinsertion follows as a second surgical intervention after decompressive craniectomy in patients with malignant middle cerebral artery (MCA) infarction. In addition to surgery-related short-term complications, aseptic resorption of the reimplanted bone flap is a possible long-term problem which has not yet been sufficiently elucidated in these patients.

Methods

A total of 109 patients who had undergone decompressive hemicraniectomy for malignant MCA infarction in our institution between September 1994 and December 2011 were included in the study. Clinical and radiological findings were retrieved retrospectively. Aseptic bone necrosis was classified into two categories based on computer tomographic features.

Results

A total of 76 patients received their own cryoconserved bone flap (mean age 54.34 ± 10.73 years; 49 males). The overall short-term complication rate was 9.2 %. Bone flap necrosis occurred in 26 patients (22.8 %) with 7 flaps showing signs of surgically relevant type II necrosis after a median time of 14 months (interquartile range [IQR] 4–22).

Conclusions

There is a noticeable complication rate in patients undergoing bone flap reinsertion after hemicraniectomy due to malignant MCA infarction. Aseptic bone necrosis represents a significant complication during long-term follow-up. The pathophysiological mechanisms remain unclear and more efforts should be undertaken to understand and possibly prevent this complication in these patients.     

Safety outcomes of Alteplase among acute ischemic stroke patients with special characteristics

Background

Although tissue plasminogen activator (tPA) has been approved for use in acute ischemic stroke, concerns linger regarding its safety. We analyzed whether patients in special subgroups (i.e., age >70 years, baseline National Institute of Health Stroke Scale (NIHSS) score >20, diabetes, congestive heart failure (CHF), and of Hispanic origin) have a higher risk of symptomatic intracerebral hemorrhage (SICH) than patients without these characteristics.

Methods

Four prospective observational studies of acute ischemic stroke patients treated within 3 h with Alteplase were identified and individual patient data were pooled for this analysis. These included the Standard Treatment with Alteplase to Reverse Stroke Study [STARS, N = 389], Epidemiology Study of Ischemic Stroke [ESIS, N = 236], University Of Texas Houston Stroke Study [UT, N = 241], and Canadian Activase For Stroke Effectiveness Study [CASES, N = 1100]. The risk of SICH was calculated for all patients and for each of five subgroups.

Results

A total of 1966 patients were studied. Overall the risk of symptomatic ICH was 4.7% (95%CI, 3.8–5.8%) and the risk was similar among patients with and without each of the five characteristics. Patients with advanced age, baseline NIHSS score >20, CHF or diabetes had increased mortality and significantly lower rate of functional recovery.

Conclusions

The present study suggests that these specified subgroups of patients are not at increased risk of SICH after stroke thrombolysis compared to those without these characteristics.     

DESTINY-S: Attitudes of Physicians Toward Disability and Treatment in Malignant MCA Infarction

Background

Decompressive hemicraniectomy (DHC) reduces mortality and improves outcome after malignant middle cerebral artery (MCA) infarction but leaves a high number of survivors severely disabled. Attitudes among physicians toward the degree of disability that is considered acceptable and the impact of aphasia may play a major role in treatment decisions.

Methods

DESTINY-S is a multicenter, international, cross-sectional survey among 1,860 physicians potentially involved in the treatment of malignant MCA infarction. Questions concerned the grade of disability, the hemisphere of the stroke, and the preferred treatment for malignant MCA infarction.

Results

mRS scores of 3 or better were considered acceptable by the majority of respondents (79.3 %). Only few considered a mRS score of 5 still acceptable (5.8 %). A mRS score of 4 was considered acceptable by 38.0 %. Involved hemisphere (dominant vs. non-dominant) was considered a major clinical symptom influencing treatment decisions in 47.7 % of respondents, also reflected by significantly different rates for DHC as preferred treatment in dominant versus non-dominant hemispheric infarction (46.9 vs. 72.9 %). Significant differences in acceptable disability and treatment decisions were found among geographic regions, medical specialties, and respondents with different work experiences.

Conclusion

Little consensus exists among physicians regarding acceptable outcome and therapeutic management after malignant MCA infarction, and physician’s recommendations do not correlate with available evidence. We advocate for a decision-making process that balances scientific evidence, patient preference, and clinical expertise.     

Prediction of Poor Outcome in Cerebellar Infarction by Diffusion MRI

Objective

Identification of patients with posterior fossa infarction at risk for neurological deterioration remains a challenge. MRI-based assessments of MCA infarction can predict poor outcome. Similar quantitative imaging measures after cerebellar stroke have not been studied. We tested the hypothesis that MRI-based volumetric assessment of cerebellar infarcts can provide reliable information for the prediction of poor outcome.

Design

We retrospectively identified 44 consecutive subjects (age 55.2 ± 13) with cerebellar stroke who underwent MRI with diffusion-weighted imaging (DWI) (median 63.7 h). Subjects were divided into poor (n = 13) and good outcomes (n = 31). Poor outcome was defined as having at least one of the following criteria: (1) mortality, (2) decompressive craniectomy, (3) ventriculostomy, and (4) decrease level of consciousness. DWI and cerebellar volume were defined on apparent diffusion coefficient maps. The ratio of the lesion volume to the whole cerebellum volume was calculated (rVolume).

Measurements and Main Results

Logistic regression revealed that lesion volume and rVolume were associated with increased risk of poor outcome, even after adjusting for age and NIHSS (χ ² = 8.2230, p < 0.0042; χ ² = 8.3992, p < 0.0038, respectively). The receiver operating characteristic curve with age, NIHSS, and volume or rVolume achieved an AUC of 0.816 (95 % CI 0.678–0.955) and 0.831 (95 % CI 0.6989–0.9636), respectively.

Conclusions

Quantitative volumetric measurement predicts poor outcome of cerebellar stroke patients, even when controlling for age and NIHSS. Quantitative analysis of diffusion MRI may assist in identification of patients with cerebellar stroke at highest risk of neurological deterioration. Prospective validation is warranted.     

Malignant MCA territory infarction in the pediatric population: subgroup analysis of the Greater Cincinnati/Northern Kentucky Stroke Study

Purpose

Malignant middle cerebral artery (MCA) infarctions are thought to be rare in children. In a recent hospital-based study, only 1.3 % of pediatric ischemic strokes were malignant MCA infarctions. However, population-based rates have not been published. We performed subgroup analysis of a population-based study to determine the rate of malignant MCA infarctions in children.

Methods

In 2005 and 2010, all ischemic stroke-related emergency visits and hospital admissions among the 1.3 million residents of the five-county Greater Cincinnati/Northern Kentucky area were ascertained. Cases that occurred in patients 18 years and younger were reviewed in detail, and corresponding clinical and neuroimaging findings were recorded. Infarctions were considered malignant if they involved 50 % or more of the MCA territory and resulted in cerebral edema and mass effect.

Results

In 2005, eight pediatric ischemic strokes occurred in the study population, none of which were malignant infarctions. In 2010, there were also eight ischemic strokes. Of these, two malignant MCA infarctions were identified: (1) a 7-year-old boy who underwent hemicraniectomy and survived with moderate disability at 30 days and (2) a 17-year-old girl with significant prestroke disability who was not offered hemicraniectomy and died following withdrawal of care. Thus, among 16 children over 2 years, there were two malignant MCA infarctions (12.5 %, 95 % CI 0–29).

Conclusions

Malignant MCA infarctions in children may not be as rare as previously thought. Given the significant survival and functional outcome benefit conferred by hemicraniectomy in adults, future studies focusing on its potential role in pediatric patients are warranted.     

Early Major Worsening in Ischemic Stroke: Predictors and Outcome

Introduction

We aimed to investigate the characteristics and outcome of patients suffering early major worsening (EMW) after acute ischemic stroke (AIS) and assess the parameters associated with it.

Methods

All consecutive patients with AIS in the ASTRAL registry until 10/2010 were included. EMW was defined as an NIHSS increase of ≥8 points within the first 24 h after admission. The Bootstrap version of the Kolmogorov–Smirnov test and the χ ²-test were used for the comparison of continuous and categorical covariates, respectively, between patients with and without EMW. Multiple logistic regression analysis was performed to identify independent predictors of EMW.

Results

Among 2155 patients, 43 (2.0 %) had an EMW. EMW was independently associated with hemorrhagic transformation (OR 22.6, 95 % CI 9.4–54.2), cervical artery dissection (OR 9.5, 95 % CI 4.4–20.6), initial dysarthria (OR 3.7, 95 % CI 1.7–8.0), and intravenous thrombolysis (OR 2.1, 95 % CI 1.1–4.3), whereas a negative association was identified with initial eye deviation (OR 0.4, 95 % CI 0.2–0.9). Favorable outcome at 3 and 12 months was less frequent in patients with EMW compared to patients without (11.6 vs. 55.3 % and 16.3 vs. 50.7 %, respectively), and case fatality was higher (53.5 vs. 12.9 % and 55.8 vs. 16.8 %, respectively). Stroke recurrence within 3 months in surviving patients was similar between patients with and without EMW (9.3 vs. 9.0 %, respectively).

Conclusions

Worsening of ≥8 points in the NIHSS score during the first 24 h in AIS patients is related to cervical artery dissection and hemorrhagic transformation. It justifies urgent repeat parenchymal and arterial imaging. Both conditions may be influenced by targeted interventions in the acute phase of stroke.