scholarly journals Early Prediction of Malignant Brain Edema After Ischemic Stroke

Stroke ◽  
2018 ◽  
Vol 49 (12) ◽  
pp. 2918-2927 ◽  
Author(s):  
Simiao Wu ◽  
Ruozhen Yuan ◽  
Yanan Wang ◽  
Chenchen Wei ◽  
Shihong Zhang ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Brain Edema ◽  
Predictive Models ◽  
Odds Ratio ◽  
National Institutes Of Health ◽  
Early Prediction ◽  
Younger Age ◽  
Scale Scores ◽  
Mean Differences

Background and Purpose— Malignant brain edema after ischemic stroke has high mortality but limited treatment. Therefore, early prediction is important, and we systematically reviewed predictors and predictive models to identify reliable markers for the development of malignant edema. Methods— We searched Medline and Embase from inception to March 2018 and included studies assessing predictors or predictive models for malignant brain edema after ischemic stroke. Study quality was assessed by a 17-item tool. Odds ratios, mean differences, or standardized mean differences were pooled in random-effects modeling. Predictive models were descriptively analyzed. Results— We included 38 studies (3278 patients) with 24 clinical factors, 7 domains of imaging markers, 13 serum biomarkers, and 4 models. Generally, the included studies were small and showed potential publication bias. Malignant edema was associated with younger age (n=2075; mean difference, −4.42; 95% CI, −6.63 to −2.22), higher admission National Institutes of Health Stroke Scale scores (n=807, median 17–20 versus 5.5–15), and parenchymal hypoattenuation >50% of the middle cerebral artery territory on initial computed tomography (n=420; odds ratio, 5.33; 95% CI, 2.93–9.68). Revascularization (n=1600, odds ratio, 0.37; 95% CI, 0.24–0.57) were associated with a lower risk for malignant edema. Four predictive models all showed an overall C statistic >0.70, with a risk of overfitting. Conclusions— Younger age, higher National Institutes of Health Stroke Scale, and larger parenchymal hypoattenuation on computed tomography are reliable early predictors for malignant edema. Revascularization reduces the risk of malignant edema. Future studies with robust design are needed to explore optimal cutoff age and National Institutes of Health Stroke Scale scores and to validate and improve existing models.

scholarly journals Acute Ischemic Stroke in Patients With COVID-19

Stroke ◽  
2021 ◽  
Vol 52 (5) ◽  
pp. 1826-1829
Author(s):  
Pratyaksh K. Srivastava ◽  
Shuaiqi Zhang ◽  
Ying Xian ◽  
Hanzhang Xu ◽  
Christine Rutan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Odds Ratio ◽  
Adverse Outcomes ◽  
National Institutes Of Health ◽  
Stroke Severity ◽  
Younger Age ◽  
Increased Risk ◽  
Scale Scores ◽  
Get With The Guidelines

Background and Purpose: Studies suggest an increased risk of adverse outcomes among patients with acute ischemic stroke (AIS) and coronavirus disease 2019 (COVID-19). Methods: Using Get With The Guidelines–Stroke, we identified 41 971 patients (AIS/COVID-19: 1143; AIS/no COVID-19: 40 828) with AIS hospitalized between February 4, 2020 and June 29, 2020, from 458 Get With The Guidelines–Stroke hospitals with at least one COVID-19 case and evaluated clinical characteristics, treatment patterns, and outcomes. Results: Compared with patients with AIS/no COVID-19, those with AIS/COVID-19 were younger, more likely to be non-Hispanic Black, Hispanic, or Asian, more likely to present with higher National Institutes of Health Stroke Scale scores, and had greater proportions of large vessel occlusions. Rates of thrombolysis and thrombectomy were similar between the groups. Door to computed tomography (median 55 [18–207] versus 35 [14–99] minutes, P <0.001), door to needle (59 [40–82] versus 46 [33–64] minutes, P <0.001), and door to endovascular therapy (114 [74–169] versus 90 [54–133] minutes, P =0.002) times were longer in the AIS/COVID-19 cohort. In adjusted models, patients with AIS/COVID-19 had decreased odds of discharge with modified Rankin Scale score of ≤2 (odds ratio, 0.65 [95% CI, 0.52–0.81], P <0.001) and increased odds of in-hospital mortality (odds ratio, 4.34 [95% CI, 3.48–5.40], P <0.001). ConclusionS: This analysis demonstrates younger age, greater stroke severity, longer times to evaluation and treatment, and worse morbidity and mortality in patients with AIS/COVID-19 compared with those with AIS/no COVID-19.

scholarly journals Reperfusion Therapy Frequency and Outcomes in Mild Ischemic Stroke in the United States

Stroke ◽  
2020 ◽  
Vol 51 (11) ◽  
pp. 3241-3249 ◽  
Author(s):  
Hamidreza Saber ◽  
Kasra Khatibi ◽  
Viktor Szeder ◽  
Satoshi Tateshima ◽  
Geoffrey P. Colby ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Intracranial Hemorrhage ◽  
Odds Ratio ◽  
Mechanical Thrombectomy ◽  
Reperfusion Therapy ◽  
Interquartile Range ◽  
Nihss Score ◽  
Discharge Disposition ◽  
Younger Age

Background and Purpose: More than half of patients with acute ischemic stroke have minor neurological deficits; however, the frequency and outcomes of reperfusion therapy in regular practice has not been well-delineated. Methods: Analysis of US National Inpatient Sample of hospitalizations with acute ischemic stroke and mild deficits (National Institutes of Health Stroke Scale [NIHSS] score 0–5) from October 1, 2016, to December 31, 2017. Patient- and hospital-level characteristics associated with use and outcome of reperfusion therapies were analyzed. Primary outcomes included excellent discharge disposition (discharge to home without assistance); poor discharge disposition (discharge to facility or death); in-hospital mortality; and radiological intracranial hemorrhage. Results: Among 179 710 acute ischemic stroke admissions with recorded NIHSS during the 15-month study period, 103 765 (57.7%) had mild strokes (47.3% women; median age, 69 [interquartile range, 59–79] years; median NIHSS score of 2 [interquartile range, 1–4]). Considering reperfusion therapies among strokes with documented NIHSS, mild deficit hospitalizations accounted for 40.0% of IVT and 10.7% of mechanical thrombectomy procedures. Characteristics associated with IVT and with mechanical thrombectomy utilization were younger age, absence of diabetes, higher NIHSS score, larger/teaching hospital status, and Western US region. Excellent discharge outcome occurred in 48.2% of all mild strokes, and in multivariable analysis, was associated with younger age, male sex, White race, lower NIHSS score, absence of diabetes, heart failure, and kidney disease, and IVT use. IVT was associated with increased likelihood of excellent outcome (odds ratio, 1.90 [95% CI, 1.71–2.13], P <0.001) despite an increased risk of intracranial hemorrhage (odds ratio, 1.41 [95% CI, 1.09–1.83], P <0.001). Conclusions: In national US practice, more than one-half of acute ischemic stroke hospitalizations had mild deficits, accounting for 4 of every 10 IVT and 1 of every 10 mechanical thrombectomy treatments, and IVT use was associated with increased discharge to home despite increased intracranial hemorrhage.

scholarly journals Clinical and Imaging Determinants of Collateral Status in Patients With Acute Ischemic Stroke in MR CLEAN Trial and Registry

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1493-1502
Author(s):  
Eveline J.A. Wiegers ◽  
Maxim J.H.L. Mulder ◽  
Ivo G.H. Jansen ◽  
Esmee Venema ◽  
Kars C.J. Compagne ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Carotid Artery ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Computed Tomography Angiography ◽  
Odds Ratio ◽  
Internal Carotid ◽  
Common Odds Ratio ◽  
Mr Clean

Background and Purpose— Collateral circulation status at baseline is associated with functional outcome after ischemic stroke and effect of endovascular treatment. We aimed to identify clinical and imaging determinants that are associated with collateral grade on baseline computed tomography angiography in patients with acute ischemic stroke due to an anterior circulation large vessel occlusion. Methods— Patients included in the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; n=500) and MR CLEAN Registry (n=1488) were studied. Collateral status on baseline computed tomography angiography was scored from 0 (absent) to 3 (good). Multivariable ordinal logistic regression analyses were used to test the association of selected determinants with collateral status. Results— In total, 1988 patients were analyzed. Distribution of the collateral status was as follows: absent (7%, n=123), poor (32%, n=596), moderate (39%, n=735), and good (23%, n=422). Associations for a poor collateral status in a multivariable model existed for age (adjusted common odds ratio, 0.92 per 10 years [95% CI, 0.886–0.98]), male (adjusted common odds ratio, 0.64 [95% CI, 0.53–0.76]), blood glucose level (adjusted common odds ratio, 0.97 [95% CI, 0.95–1.00]), and occlusion of the intracranial segment of the internal carotid artery with occlusion of the terminus (adjusted common odds ratio 0.50 [95% CI, 0.41–0.61]). In contrast to previous studies, we did not find an association between cardiovascular risk factors and collateral status. Conclusions— Older age, male sex, high glucose levels, and intracranial internal carotid artery with occlusion of the terminus occlusions are associated with poor computed tomography angiography collateral grades in patients with acute ischemic stroke eligible for endovascular treatment.

scholarly journals Endovascular Treatment Effect Diminishes With Increasing Thrombus Perviousness

Stroke ◽  
2021 ◽  
Author(s):  
Manon Kappelhof ◽  
Manon L. Tolhuisen ◽  
Kilian M. Treurniet ◽  
Bruna G. Dutra ◽  
Heitor Alves ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Infarct Volume ◽  
Treatment Allocation ◽  
Common Odds Ratio

Background and Purpose: Thrombus perviousness estimates residual flow along a thrombus in acute ischemic stroke, based on radiological images, and may influence the benefit of endovascular treatment for acute ischemic stroke. We aimed to investigate potential endovascular treatment (EVT) effect modification by thrombus perviousness. Methods: We included 443 patients with thin-slice imaging available, out of 1766 patients from the pooled HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials) data set of 7 randomized trials on EVT in the early window (most within 8 hours). Control arm patients (n=233) received intravenous alteplase if eligible (212/233; 91%). Intervention arm patients (n=210) received additional EVT (prior alteplase in 178/210; 85%). Perviousness was quantified by thrombus attenuation increase on admission computed tomography angiography compared with noncontrast computed tomography. Multivariable regression analyses were performed including multiplicative interaction terms between thrombus attenuation increase and treatment allocation. In case of significant interaction, subgroup analyses by treatment arm were performed. Our primary outcome was 90-day functional outcome (modified Rankin Scale score), resulting in an adjusted common odds ratio for a one-step shift towards improved outcome. Secondary outcomes were mortality, successful reperfusion (extended Thrombolysis in Cerebral Infarction score, 2B–3), and follow-up infarct volume (in mL). Results: Increased perviousness was associated with improved functional outcome. After adding a multiplicative term of thrombus attenuation increase and treatment allocation, model fit improved significantly ( P =0.03), indicating interaction between perviousness and EVT benefit. Control arm patients showed significantly better outcomes with increased perviousness (adjusted common odds ratio, 1.2 [95% CI, 1.1–1.3]). In the EVT arm, no significant association was found (adjusted common odds ratio, 1.0 [95% CI, 0.9–1.1]), and perviousness was not significantly associated with successful reperfusion. Follow-up infarct volume (12% [95% CI, 7.0–17] per 5 Hounsfield units) and chance of mortality (adjusted odds ratio, 0.83 [95% CI, 0.70–0.97]) decreased with higher thrombus attenuation increase in the overall population, without significant treatment interaction. Conclusions: Our study suggests that the benefit of best medical care including alteplase, compared with additional EVT, increases in patients with more pervious thrombi.

scholarly journals Adiposity and Outcome After Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (1) ◽  
pp. 144-151
Author(s):  
Zuolu Liu ◽  
Nerses Sanossian ◽  
Sidney Starkman ◽  
Gilda Avila-Rinek ◽  
Marc Eckstein ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Scale Score ◽  
Odds Ratio ◽  
Functional Outcomes ◽  
National Institutes Of Health ◽  
Modified Rankin Scale ◽  
Related Quality ◽  
Severely Obese

Background and Purpose: A survival advantage among individuals with higher body mass index (BMI) has been observed for diverse acute illnesses, including stroke, and termed the obesity paradox. However, prior ischemic stroke studies have generally tested only for linear rather than nonlinear relations between body mass and outcome, and few studies have investigated poststroke functional outcomes in addition to mortality. Methods: We analyzed consecutive patients with acute ischemic stroke enrolled in a 60-center acute treatment trial, the NIH FAST-MAG acute stroke trial. Outcomes at 3 months analyzed were (1) death; (2) disability or death (modified Rankin Scale score, 2–6); and (3) low stroke-related quality of life (Stroke Impact Scale<median). Relations with BMI were analyzed univariately and in multivariate models adjusting for 14 additional prognostic variables. Results: Among 1033 patients with acute ischemic stroke, average age was 71 years (±13), 45.1% female, National Institutes of Health Stroke Scale 10.6 (±8.3), and BMI 27.5 (±5.6). In both unadjusted and adjusted analysis, increasing BMI was linearly associated with improved 3-month survival ( P =0.01) odds ratios in adjusted analysis for mortality declined across the BMI categories of underweight (odds ratio, 1.7 [CI, 0.6–4.9]), normal (odds ratio, 1), overweight (0.9 [CI, 0.5–1.4]), obese (0.5, [CI, 0.3–1.0]), and severely obese (0.4 [CI, 0.2–0.9]). In unadjusted analysis, increasing BMI showed a U-shaped relation to poststroke disability or death (modified Rankin Scale score, 2–6), with odds ratios of modified Rankin Scale score, 2 to 6 for underweight, overweight, and obese declined initially when compared with normal weight patients, but then increased again in severely obese patients, suggesting a U-shaped or J-shaped relation. After adjustment, including for baseline National Institutes of Health Stroke Scale, modified Rankin Scale score 2 to 6 was no longer related to adiposity. Conclusions: Mortality and functional outcomes after acute ischemic stroke have disparate relations with patients’ adiposity. Higher BMI is linearly associated with increased survival; and BMI has a U-shaped or J-shaped relation to disability and stroke-related quality of life. Potential mechanisms including nutritional reserve aiding survival during recovery and greater frequency of atherosclerotic than thromboembolic infarcts in individuals with higher BMI.

EARLY PREDICTION OF ACUTE ISCHEMIC STROKE OUTCOME BY USING ALBERTA STROKE PROGRAM EARLY CT SCORE (ASPECTS)

2014 ◽  
pp. 168-176
Author(s):  
Vu Xuan Loc Doan ◽  
Thanh Thao Nguyen ◽  
Minh Loi Hoang ◽  
Trong Hao Vo
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Independent Predictor ◽  
Univariate Analysis ◽  
Early Prediction ◽  
Stroke Outcome ◽  
Good Outcome ◽  
Poor Outcome

Background and Purpose: The Alberta Stroke Program Early CT Score (ASPECTS) scale semiquantitatively assesses extent and location of ischemic changes within the middle cerebral artery (MCA) territory using a 10-point grading system. ASPECTS measured at baseline using noncontrast computed tomography (CT) scan. The aim of this study was to assess early prediction of clinical outcome after acute ischemic stroke by ASPECTS scale. Methods: The study based on convenience sample which included 82 first-ever acute ischemic stroke patients, admitted to Hue Central Hospital within 72 hours of stroke onset, from October 2013 to October 2014. Ischemic territory changes were defined as parenchymal CT hypoattenuation. We assessed all baseline CT scans, dichotomized ASPECTS at ≤ 7 and >7, defined good outcome (0 to 2) and poor outcome (3 to 6) as modified Rankin Scale (mRS) score at discharge. Univariate analysis and multivariable logistic regression analysis were performed to define the independent predictors for stroke outcome. Results: Mean age was 68.35 ± 13.93 years, proportion of male (51.2%) and female (48.8%) are approximately the same. ASPECTS score > 7 in 57 patients and ≤ 7 in 25 patients. Mean ASPECTS was 7.51 ± 2.25. Mean mRS at discharge was 2.28 ± 1.33. Good outcome (mRS ≤ 2) and poor outcome (mRS > 2) at discharge were 63.4% and 36.6% respectively. There is a negative correlation between ASPECTS and mRS (r = -0.86, p < 0.001). In the univariate analysis, atrial fibrillation, Glasgow Coma Scale (GCS) score at admisison, ASPECT score and infarct volume were significantly associated with stroke outcome. All of aforementioned variables underwent multivariate analysis, but none of them was proven to be an independent predictor of early outcome. Conclusion: In patients with first-ever acute ischemic stroke, ASPECT score which bases on conventional computed tomography scan is not independent predictor for clinical outcome at discharge. Key words: ischemic stroke, ASPECTS, outcome

Radiographic Characteristics of Mild Ischemic Stroke Patients With Visible Intracranial Occlusion: The INTERRSeCT Study

Stroke ◽  
2021 ◽  
Author(s):  
H. Lee Lau ◽  
Hannah Gardener ◽  
Shelagh B. Coutts ◽  
Vasu Saini ◽  
Thalia S. Field ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Scale Score ◽  
Cerebral Artery ◽  
Odds Ratio ◽  
Arterial Occlusion ◽  
National Institutes Of Health ◽  
Collateral Flow ◽  
Residual Flow ◽  
Intravenous Alteplase ◽  
Multicenter Prospective Study

Background and Purpose: Early neurological deterioration occurs in one-third of mild strokes primarily due to the presence of a relevant intracranial occlusion. We studied vascular occlusive patterns, thrombus characteristics, and recanalization rates in these patients. Methods: Among patients enrolled in INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography), a multicenter prospective study of acute ischemic strokes with a visible intracranial occlusion, we compared characteristics of mild (National Institutes of Health Stroke Scale score, ≤5) to moderate/severe strokes. Results: Among 575 patients, 12.9% had a National Institutes of Health Stroke Scale score ≤5 (median age, 70.5 [63–79]; 58% male; median National Institutes of Health Stroke Scale score, 4 [2–4]). Demographics and vascular risk factors were similar between the two groups. As compared with those with a National Institutes of Health Stroke Scale score >5, mild patients had longer symptom onset to assessment times (onset to computed tomography [240 versus 167 minutes] and computed tomography angiography [246 versus 172 minutes]), more distal occlusions (M3, anterior cerebral artery and posterior cerebral artery; 22% versus 6%), higher clot burden score (median, 9 [6–9] versus 6 [4–9]), similar favorable thrombus permeability (residual flow grades I–II, 21% versus 19%), higher collateral flow (9.1 versus 7.6), and lower intravenous alteplase treatment rates (55% versus 85%). Mild patients were more likely to recanalize (revised arterial occlusion scale score 2b/3, 45%; 49% with alteplase) compared with moderate/severe strokes (26%; 29% with alteplase). In an adjusted model for sex, alteplase, residual flow, and time between the two vessel imagings, intravenous alteplase use (odds ratio, 3.80 [95% CI, 1.11–13.00]) and residual flow grade (odds ratio, 8.70 [95% CI, 1.26–60.13]) were associated with successful recanalization among mild patients. Conclusions: Mild strokes with visible intracranial occlusions have different vascular occlusive patterns but similar thrombus permeability compared with moderate/severe strokes. Higher thrombus permeability and alteplase use were associated with successful recanalization, although the majority do not recanalize. Randomized controlled trials are needed to assess the efficacy of new thrombolytics and endovascular therapy in this population.

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