scholarly journals Heads Up! A Novel Provocative Maneuver to Guide Acute Ischemic Stroke Management

2016 ◽  
Vol 6 (1-2) ◽  
pp. 8-15 ◽  
Author(s):  
Latisha K. Ali ◽  
Julius K. Weng ◽  
Sidney Starkman ◽  
Jeffrey L. Saver ◽  
Doojin Kim ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Artery Occlusion ◽  
Final Outcome ◽  
Stroke Management ◽  
Anterior Circulation ◽  
Nihss Score ◽  
Endovascular Recanalization ◽  
Acute Cerebral Ischemia

Background: A common dilemma in acute ischemic stroke management is whether to pursue recanalization therapy in patients with large vessel occlusions but minimal neurologic deficits. We describe and report preliminary experience with a provocative maneuver, i.e. 90-degree elevation of the head of bed for 30 min, which stresses collaterals and facilitates decision-making. Methods: A prospective cohort study of <7.5 h of acute anterior circulation territory ischemia patients with minimal deficits despite middle cerebral artery (MCA) or internal carotid artery (ICA) occlusive disease. Results: Five patients met the study entry criteria. Their mean age was 78.4 years (range 65-93). All presented with substantial deficits (median NIHSS score 11, range 5-22), but improved while in supine position during initial imaging to normal or near-normal (NIHSS score 0-2). MRA showed persistent M1 MCA occlusions in 4, critical ICA stenosis or occlusion in 1, and substantial perfusion-diffusion mismatch in all. To evaluate the potential for eventual collateral failure, patients were placed in a head of bed upright posture. Mean arterial pressure and heart rate were unchanged. Two showed no neurologic worsening and were treated with supportive care with excellent final outcome. Three showed worsening, including recurrent hemiparesis and aphasia at the 6th, recurrent aphasia at the 23rd, and recurrent hemineglect at the 15th upright minute. These 3 underwent endovascular recanalization therapies with successful reperfusion and excellent final outcome. Conclusion: The ‘Heads Up' test may be a useful, simple maneuver to assess the risk of collateral failure and guide the decision to pursue recanalization therapy in acute cerebral ischemia patients with minimal deficits despite persisting large cerebral artery occlusion.

scholarly journals Endovascular Recanalization in Early Recurrent Ischemic Stroke: A Treatment Challenge

2020 ◽  
Vol 12 (Suppl. 1) ◽  
pp. 49-55
Author(s):  
Huong Bich Thi Nguyen ◽  
Thang Huy Nguyen
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Time Window ◽  
Recurrent Stroke ◽  
Reperfusion Therapy ◽  
Artery Occlusion ◽  
Large Artery ◽  
Limited Information ◽  
Anterior Circulation ◽  
Endovascular Recanalization

Reperfusion therapy is the most effective treatment for acute ischemic stroke. At present, many clinical studies have shown that mechanical thrombectomy is efficient and safe for acute ischemic stroke of large artery occlusion disease in the time window of 24 h. However, there is limited information on the safety and effectiveness of this technique in cases of recurrent ischemic stroke. We report a case of early recurrent stroke of the anterior circulation after a week of the first stroke. Imaging examinations showed that there existed occlusion of corresponding vessels and obvious ischemic penumbra. Symptoms of the patient were progressive worsening and medical treatment failed; therefore, the corresponding vessel was opened. The low perfusion status in brain tissue and clinical defect symptoms of the patients have improved a lot. In conclusion, thrombectomy for early recurrent ischemic stroke may be effective. Moreover, there may be a wider reperfusion time window for ischemic stroke patients.

Tenacity of Collateral Perfusion in Proximal Cerebral Arterial Occlusions 6–12 h after Onset

2018 ◽  
Vol 45 (5-6) ◽  
pp. 263-269 ◽  
Author(s):  
Beom Joon Kim ◽  
Hyeran Kim ◽  
Han-Gil Jeong ◽  
Mi Hwa Yang ◽  
Cheol Kyu Jung ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Binary Logistic Regression ◽  
Artery Occlusion ◽  
Binary Logistic Regression Analysis ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Clinical Registry ◽  
Stroke Registry ◽  
Endovascular Recanalization

Background: Clinical trials have shown that benefits of endovascular recanalization (EVT) for acute ischemic stroke patients with sizable penumbral tissues seems plausible even beyond 6 h after their last seen normal (LSN). Persistency of ischemic penumbra remains unclear in delayed periods. Methods: From a prospective stroke registry database, we identified 111 acute ischemic stroke patients who had internal carotid artery or middle cerebral artery occlusion with baseline National Institutes of Health Stroke Scale scores ≥6 points and arrived 6–12 h after LSN. Baseline information and functional outcomes were prospectively collected as a clinical registry. Attending physicians made treatment decisions for EVT based on the current guidelines and institutional protocols. MR image parameters, including the volume of diffusion-restricted lesions and mapping of the ­hypoperfused area, were quantified using automated commercial software. Binary logistic regression analysis models, with modified Rankin Scale (mRS) scores of 0–1 at 3 months after stroke included as a dependent variable, were constructed. Results: Between 6 and 12 h after onset, 58% had a mismatch ratio of ≥1.8 at baseline and 42% had favorable imaging profiles as determined by DEFUSE 2 study. After 9 h, there was a mismatch ratio of ≥1.8 in 47 and 38% favorable profiles. EVT was performed in 54% of cases. A 3-month mRS score of 0–1 was found in 19% (25% in EVT and 12% in medical treatment groups) of cases. EVT was associated with an increased OR of having a mRS score of 0–1 at 3 months after stroke (adjusted OR 7.59 [95% CI 1.28–61.60]). Conclusions: Penumbral tissues were persistent in a substantial proportion of anterior circulation occlusion cases 6–12 h after LSN. EVT at 6–12 h in a predominantly Asian cohort resulted in better outcomes.

scholarly journals Solitaire stent in the treatment of acute ischemic stroke with large cerebral artery occlusion

2017 ◽  
Vol 8 (1) ◽  
Author(s):  
Wenbao Liang ◽  
Zhijie Ou ◽  
Rui Luo
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Artery Occlusion ◽  
Functional Score ◽  
Infarct Core ◽  
Anterior Circulation ◽  
Level 3 ◽  
Cerebral Artery Occlusion

AbstractObjectiveTo investigate the effect of mechanical thrombectomy with solitaire stent in the treatment of acute ischemic stroke with large cerebral artery occlusion.MethodsFifteen acute ischemic stroke patients with a proximal intracranial occlusion in the anterior circulation were included within 6 hours after symptom onset (unknown time of onset allowed in wake upstroke). Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded. All patients were measured by the National Institutes of Health Stroke Scale (NIHSS) before and 24 hours after the procedure. The primary outcomes were reperfusion at 24 hours and a Thrombolysis in Cerebral Infarction (TICI) score of 2b or 3 indicates successful reperfusion. Secondary outcomes included the functional score on the Modified Rankin Scale(MRS) and NIHSS score at 90 days. Good Functional Outcome (GFO), is defined as mRS0–2 at 90 days.ResultsThe preoperative TICI grading of these 15 patients were all level 0.14 patients were level 2b to level 3 after the thrombectomy, 1 ipsilateral cervical carotid occlusion patient failed recanalization.14 patients with reperfusion at 24 hours showed good early neurologic improvement. The MRS score of all the 14 patients were<2 point at 90 days. There were no obvious adverse reactions and complications in these patients after mechanical thrombectomy.ConclusionThe application of mechanical thrombectomy with solitaire stent for the treatment of acute ischemic stroke with large cerebral artery occlusion is safe and time-efficient, which could improve the recanalization rate, decrease or even eliminate the application of thrombolytic drugs and reduce the rate of intracranial hemorrhage. Awake stroke patient can also benefit from thrombectomy.

Efficacy and Safety of Timely Urgent Superficial Temporal Artery-to-Middle Cerebral Artery Bypass Surgery in Patients with Acute Ischemic Stroke: A Single-Institutional Prospective Study and a Pooled Analysis

2021 ◽  
pp. 1-12
Author(s):  
Jang Hun Kim ◽  
Wonki Yoon ◽  
Chi Kyung Kim ◽  
Haewon Roh ◽  
Hee Jin Bae ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Bypass Surgery ◽  
Superficial Temporal Artery ◽  
Pooled Analysis ◽  
Published Data ◽  
Efficacy And Safety ◽  
Nihss Score

<b><i>Background:</i></b> Clinical outcome in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) is not satisfactory if reperfusion treatment fails or is not tried. <b><i>Aims:</i></b> We aimed to assess the efficacy and safety of urgent superficial temporal-to-middle cerebral artery (STA-MCA) bypass surgery in selected patients. <b><i>Methods:</i></b> Patients who were diagnosed with LVO-induced AIS in the anterior circulation but had a failed intra-arterial thrombectomy (IAT) or were not tried due to IAT contraindications were prospectively enrolled. Timely urgent STA-MCA bypass surgery was performed if they showed perfusion-diffusion mismatch or symptom-diffusion mismatch in the acute phase of disease. Clinical and radiological data of these patients were assessed to demonstrate the safety and efficacy of urgent bypass procedures. A pooled analysis of published data on urgent bypass surgery in acute stroke patients was conducted and analyzed. <b><i>Results:</i></b> In 18 patients who underwent timely bypass, the National Institutes of Health Stroke Scale (NIHSS) score improved from 12.11 ± 4.84 to 9.89 ± 6.52, 1 week after surgery. Three-month and long-term (9.72 ± 5.00 months) favorable outcomes (modified Rankin Scale [mRS] scores 0–2) were achieved in 50 and 75% of the patients, respectively. The pooled analysis (117 patients from 10 articles, including ours) identified favorable mRS scores in 71.79% patients at 3 months. A significant NIHSS score improvement from 11.51 ± 4.89 to 7.59 ± 5.50 was observed after surgery with significance. Major complications occurred in 3 patients (2.6%, 3/117) without mortality. <b><i>Conclusions:</i></b> Urgent STA-MCA bypass surgery can be regarded as a safe optional treatment to prevent cerebral infarct expansion and to improve clinical and radiological outcomes in highly selected patients.

Abstract WP1: Thrombectomy Outcomes in Acute Ischemic Stroke due to Middle Cerebral Artery M2 Occlusion with Stent-Retriever, Aspiration, MERCI: Multi-Center Experience

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Kunakorn Atchaneeyasakul ◽  
Amer M Malik ◽  
Dileep R Yavagal ◽  
Mehdi Bouslama ◽  
Diogo C Haussen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Tertiary Care ◽  
Stent Retriever ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Significant Difference

Introduction: Recent trials demonstrated that mechanical thrombectomy improve functional outcome in anterior circulation acute ischemic stroke (AIS) due to emergent large vessel occlusion (ELVO) of the middle cerebral artery (MCA) M1 segment. However, such data regarding AIS due to MCA M2 segment ELVO is limited. Analysis of the STAR, SWIFT, and SWIFT-PRIME trials found thrombectomy in MCA M2 occlusion to be feasible in achieving successful reperfusion. The most optimal technique and/or device used for such reperfusion is not clearly defined. We aim to compare the outcome for the contemporary techniques and devices used for thrombectomy of AIS patients due to MCA M2 ELVO. Methods: A retrospective review of AIS patients with MCA M2 ELVO receiving thrombectomy from three tertiary care academic medical centers was conducted. Thrombectomy technique and thrombectomy device utilized were recorded. Outcomes were successful angiographic reperfusion (TICI ≥2b), favorable modified Rankin Scale (mRS≤2) at discharge and at 90 days, and rate of symptomatic intracerebral hemorrhage (sICH). Results: From October 1999 through June 2016, 253 AIS patients underwent thrombectomy for MCA M2 ELVO. Thrombectomy methods utilized were Stent-retriever (n=118), Aspiration only [manual or Penumbra device] (n=83), and MERCI retriever (n=52). Table 1 shows rate of outcomes measured. There was no difference in baseline NIHSS or in stroke onset to groin puncture time. Stent-retriever group showed a significantly higher recanalization rate, lower sICH rate, and favorable 90-day mRS versus Aspiration group or MERCI group, respectively. No significant difference was seen in discharge mRS between the groups. Conclusions: Thrombectomy for AIS patients with MCA M2 ELVO with Stent-retriever appears to be feasible with a significantly higher rate of recanalization, lower sICH rate, and favorable 90-day mRS when compared to Aspiration and MERCI.

Capillary Index Score Derived from Computed Tomography Angiography as An Indicator of Collateral Flow after Acute Ischemic Stroke

2019 ◽  
Author(s):  
Shang Kai ◽  
Xiaoxing Zhang ◽  
Yuehua Li
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cerebral Artery ◽  
Treatment Strategies ◽  
Artery Occlusion ◽  
Index Score ◽  
Collateral Flow ◽  
Imaging Data ◽  
Flow Group ◽  
Cerebral Artery Occlusion

Abstract Background The capillary index score (CIS) determined from DSA is used to evaluate cerebral collateral flow in acute ischemic stroke (AIS) caused by cerebral artery occlusion. Our aim was to determine the reliability of CIS calculated from MIP-CTA images as an alternative to DSA-based CIS, as CTA is less invasive and less expensive. Methods Clinical and imaging data of 40 patients with AIS caused by cerebral artery occlusion within 6 h from symptom onset were collected. CIS was calculated from CTA and DSA images. Patients were classified into the favorable collateral flow group if CIS was ≥2 (fCIS), and into the poor collateral flow group if CIS was <2 (pCIS). Agreement between the methods was evaluated using the Kappa test. Logistic regression was performed to explore the relationship between CTA-based CIS and clinical outcomes. Results The two methods had high consistency (Kappa = 0.72), and the diagnostic accuracy of CTA for CIS classification was 87.5%. The decrease in the NIHSS score at discharge was not significantly different between the fCIS and pCIS groups according to CTA (p = 0.156), while the 90-day mRS was higher in the pCIS group (p = 0.04). High CTA-based CIS and low blood glucose at admission were significantly correlated with good outcome. Conclusion CIS calculated using CTA is as reliable as DSA-based CIS for assessing collateral flow in AIS, and is also a good predictor of clinical outcome. This index could be useful for guiding patient selection and treatment strategies for AIS.

Leukoaraiosis and acute ischemic stroke: 90-day clinical outcome following endovascular recanalization, with proposed “L-ASPECTS”

2020 ◽  
pp. neurintsurg-2020-015957 ◽  
Author(s):  
John Benson ◽  
Seyed Mohammad Seyedsaadat ◽  
Ian Mark ◽  
Deena M Nasr ◽  
Alejandro A Rabinstein ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Area Under The Curve ◽  
Primary Outcome Measure ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Endovascular Recanalization ◽  
Poor Outcomes

BackgroundTo assess if leukoaraiosis severity is associated with outcome in patients with acute ischemic stroke (AIS) following endovascular thrombectomy, and to propose a leukoaraiosis-related modification to the ASPECTS score.MethodsA retrospective review was completed of AIS patients that underwent mechanical thrombectomy for anterior circulation large vessel occlusion. The primary outcome measure was 90-day mRS. A proposed Leukoaraiosis-ASPECTS (“L-ASPECTS”) was calculated by subtracting from the traditional ASPECT based on leukoaraiosis severity (1 point subtracted if mild, 2 if moderate, 3 if severe). L-ASEPCTS score performance was validated using a consecutive cohort of 75 AIS LVO patients.Results174 patients were included in this retrospective analysis: average age: 68.0±9.1. 28 (16.1%) had no leukoaraiosis, 66 (37.9%) had mild, 62 (35.6%) had moderate, and 18 (10.3%) had severe. Leukoaraiosis severity was associated with worse 90-day mRS among all patients (P=0.0005). Both L-ASPECTS and ASPECTS were associated with poor outcomes, but the area under the curve (AUC) was higher with L-ASPECTS (P<0.0001 and AUC=0.7 for L-ASPECTS; P=0.04 and AUC=0.59 for ASPECTS). In the validation cohort, the AUC for L-ASPECTS was 0.79 while the AUC for ASPECTS was 0.70. Of patients that had successful reperfusion (mTICI 2b/3), the AUC for traditional ASPECTS in predicting good functional outcome was 0.80: AUC for L-ASPECTS was 0.89.ConclusionsLeukoaraiosis severity on pre-mechanical thrombectomy NCCT is associated with worse 90-day outcome in patients with AIS following endovascular recanalization, and is an independent risk factor for worse outcomes. A proposed L-ASPECTS score had stronger association with outcome than the traditional ASPECTS score.

scholarly journals Prospective Endovascular Treatment in Acute Ischemic Stroke Evaluating Non-Contrast Head CT versus CT Perfusion (PLEASE No CTP)

2019 ◽  
Vol 8 (2-6) ◽  
pp. 116-122
Author(s):  
Ameer E. Hassan ◽  
Hafsah Shamim ◽  
Haralabos Zacharatos ◽  
Saqib A. Chaudhry ◽  
Christina Sanchez ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Ct Perfusion ◽  
Treatment Decision ◽  
Anterior Circulation ◽  
Nihss Score ◽  
Contrast Ct

Background: Studies have shown a lack of agreement of computed tomography perfusion (CTP) in the selection of acute ischemic stroke (AIS) patients for endovascular treatment. Purpose: To demonstrate whether non-contrast computed tomography (CT) within 8 h of symptom onset is comparable to CTP imaging. Methods: Prospective study of consecutive anterior circulation AIS patients with a National Institute of Health Stroke Scale (NIHSS) score > 7 presenting within 8 h of symptom onset with endovascular treatment. All patients had non-contrast CT, CT angiography, and CTP. The neuro-interventionalist was blinded to the results of the CTP and based the treatment decision using the Alberta Stroke Program Early CT score (ASPECTS). Baseline demographics, co-morbidities, and baseline NIHSS scores were collected. Outcomes were modified Rankin scale (mRS) score at discharge and in-hospital mortality. Good outcomes were defined as a mRS score of 0–2. Results: 283 AIS patients were screened for the trial, and 119 were enrolled. The remaining patients were excluded for: posterior circulation stroke, no CTP performed, could not obtain consent, and NIHSS score < 7. Mean ­NIHSS score at admission was 16.8 ± 3, and mean ASPECTS was 8.4 ± 1.4. There was no statistically significant correlation with CTP penumbra and good outcomes: 50 versus 47.8% with no penumbra present (p = 0.85). In patients without evidence of CTP penumbra, there was 22.5% mortality compared to 22.1% mortality in patients with a CTP penumbra. If ASPECTS ≥7, 64.6% had good outcome versus 13.3% if ASPECTS < 7 (p < 0.001). Patients with an ASPECTS ≥7 had 10% mortality versus 51.4% in patients with an ASPECTS < 7 (p < 0.001). Conclusions: CTP penumbra did not identify patients who would benefit from endovascular treatment when patients were selected with non-contrast CT ASPECTS ≥7. There is no correlation of CTP penumbra with good outcomes or mortality. Larger prospective trials are warranted to justify the use of CTP within 6 h of symptom onset.

Initial factors affecting the clinical outcome after successful recanalization via MR-based mechanical thrombectomy in patients with acute ischemic stroke due to basilar artery occlusion

2015 ◽  
Vol 8 (9) ◽  
pp. 889-893 ◽  
Author(s):  
Seungnam Son ◽  
Yong-Won Kim ◽  
Min Kyun Oh ◽  
Soo-Kyoung Kim ◽  
Ki-Jong Park ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Basilar Artery ◽  
Mechanical Thrombectomy ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Nihss Score ◽  
Diffusion Weighted Images ◽  
Outcome Group

Background and purposeTo determine the initial factors, including patient characteristics, stroke etiology and severity, time factors, and imaging findings, that could affect the clinical outcome of patients with acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) where successful recanalization was achieved via mechanical thrombectomy.MethodsBetween March 2011 and December 2014, 35 patients with AIS caused by BAO received MRI/MR angiography-based mechanical thrombectomies, and recanalization was achieved with a Thrombolysis In Cerebral Infarction score of >2b. The patients were divided into a good outcome group (n=19), defined as those with a modified Rankin Scale (mRS) score of 0–2 at 3 months after stroke onset, and a poor outcome group (n=16), defined as a mRS score of 3–6. The differences between the groups were analyzed.ResultsInitial National Institutes of Health Stroke Scale (NIHSS) score (good vs poor: 17.9±8.9 vs 27.6±8.5, p=0.003), posterior circulation Acute Stroke Prognosis Early CT Score (pc-ASPECTS) based on initial diffusion-weighted images (DWI) (good vs poor: 7.8±1.6 vs 5.4±1.8, p=0.001), pc-ASPECTS based on contrast staining on the post-thrombectomy control CT (good vs poor: 9.2±1.5 vs 6.3±2.2, p<0.001), and presence of contrast staining in the brainstem on that CT (good vs poor: 15.8% vs 81.6%, p<0.001) were significantly different between the groups.ConclusionsPatients with AIS caused by BAO with a lower initial NIHSS score, fewer lesions on initial DWI, and less contrast staining on the post-thrombectomy control CT have higher probabilities of a good clinical outcome after successful recanalization via a mechanical thrombectomy.

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