scholarly journals Optimal Tissue Reperfusion Estimation by Computed Tomography Perfusion Post-Thrombectomy in Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Zefeng Tan ◽  
Mark Parsons ◽  
Andrew Bivard ◽  
Gagan Sharma ◽  
Peter Mitchell ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Endovascular Therapy ◽  
Odds Ratio ◽  
Strongly Correlated ◽  
Computed Tomography Perfusion ◽  
Magnetic Resonance Perfusion ◽  
Tissue Plasminogen ◽  
Before And After ◽  
The Difference ◽  
Favorable Functional Outcome

Background and Purpose: Modified Thrombolysis in Cerebral Infarction score (mTICI) ≥2b is defined as successful reperfusion. However, mTICI has rarely been correlated with dynamic perfusion imaging postendovascular therapy for acute stroke. We aimed to study the proportion of tissue optimal reperfusion (TOR) postendovascular therapy across different grades of mTICI. Methods: We conducted a single-center retrospective analysis of patients with acute ischemic strokes who had endovascular therapy between 2018 and 2019. Computer tomography perfusion or magnetic resonance perfusion was performed before and after endovascular therapy. Tmax+6 volume reduction of >90% was defined as TOR. Comparisons of proportions of TOR in different grades of mTICI were performed. In the present study, the requirement for informed consents was waived. Results: Eighty-two patients were included. The difference in the proportion of TOR for TICI categories was statistically significant (mTICI score 0, 0%, mTICI score 2A, 0%, mTICI score 2b, 50.0%, mTICI score 2c, 80.0%, mTICI score 3, 81.3%, χ 2 =14.035, P =0.003). Multivariable logistic regression showed that lower age (odds ratio, 0.932, P =0.017), onset-to-tissue plasminogen activator time (odds ratio, 0.980, P =0.005) and TOR (odds ratio, 8.764, P =0.031) were associated with favorable functional outcome. Conclusions: The proportion of TOR achieved by mTICI score of 2b was significantly lower than mTICI score of 2c and mTICI score of 3. TOR was associated with favorable functional outcome, and the degree of reperfusion was more strongly correlated with outcomes than the mTICI scores.

Dual antiplatelet therapy pretreatment in IV thrombolysis for acute ischemic stroke

Neurology ◽  
2018 ◽  
Vol 91 (11) ◽  
pp. e1067-e1076 ◽  
Author(s):  
Georgios Tsivgoulis ◽  
Nitin Goyal ◽  
Ali Kerro ◽  
Aristeidis H. Katsanos ◽  
Rashi Krishnan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Propensity Score ◽  
Confidence Interval ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Intracranial Hemorrhage ◽  
Odds Ratio ◽  
Dual Antiplatelet Therapy ◽  
Safety And Efficacy ◽  
Favorable Functional Outcome

ObjectiveWe sought to determine the safety and efficacy of IV thrombolysis (IVT) in acute ischemic stroke (AIS) patients with a history of dual antiplatelet therapy pretreatment (DAPP) in a prospective multicenter study.MethodsWe compared the following outcomes between DAPP+ and DAPP− IVT-treated patients before and after propensity score matching (PSM): symptomatic intracranial hemorrhage (sICH), asymptomatic intracranial hemorrhage, favorable functional outcome (modified Rankin Scale score 0–1), and 3-month mortality.ResultsAmong 790 IVT patients, 58 (7%) were on DAPP before stroke (mean age 68 ± 13 years; 57% men; median NIH Stroke Scale score 8). DAPP+ patients were older with more risk factors compared to DAPP− patients. The rates of sICH were similar between groups (3.4% vs 3.2%). In multivariable analyses adjusting for potential confounders, DAPP was associated with higher odds of asymptomatic intracranial hemorrhage (odds ratio = 3.53, 95% confidence interval: 1.47–8.47; p = 0.005) but also with a higher likelihood of 3-month favorable functional outcome (odds ratio = 2.41, 95% confidence interval: 1.06–5.46; p = 0.035). After propensity score matching, 41 DAPP+ patients were matched to 82 DAPP− patients. The 2 groups did not differ in any of the baseline characteristics or safety and efficacy outcomes.ConclusionsDAPP is not associated with higher rates of sICH and 3-month mortality following IVT. DAPP should not be used as a reason to withhold IVT in otherwise eligible AIS candidates.Classification of evidenceThis study provides Class III evidence that for IVT-treated patients with AIS, DAPP is not associated with a significantly higher risk of sICH. The study lacked the precision to exclude a potentially meaningful increase in sICH bleeding risk.

scholarly journals Risk of unruptured aneurysm treatment in California

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 381-381
Author(s):  
S. Claiborne Johnston ◽  
Shoujun Zhao ◽  
R. Adams Dudley ◽  
Daryl R Gress
Keyword(s):  
Adverse Events ◽  
Cerebral Aneurysm ◽  
Endovascular Therapy ◽  
Odds Ratio ◽  
Cerebral Aneurysms ◽  
Hospital Treatment ◽  
Hospital Death ◽  
Hospital Deaths ◽  
The Difference ◽  
Unruptured Cerebral Aneurysms

P230 Background. Few studies have directly compared the risk of cerebral aneurysm repair with surgery and with endovascular coil embolization. Since the vast majority of patients with unruptured cerebral aneurysms are non-disabled prior to treatment, this diagnosis provides an opportunity to compare risks of treatment. Methods. Discharge abstracts for all patients with a primary diagnosis of unruptured cerebral aneurysm were retrieved from a statewide database of non-Federal hospital discharges in California from January 1990 through December 1998. Admissions for initial treatment and all follow-up care were combined to reflect the entire course of therapy. An adverse event was defined as an in-hospital death or discharge to nursing home or rehabilitation hospital at any point during the treatment course. Results. A total of 2069 patients were treated for unruptured aneurysms. Adverse outcomes were more frequent in the 1699 patients treated with surgery than in the 370 treated with endovascular therapy (25% vs. 10%; p<0.0001 by chi-square test). The difference persisted after adjustment for age, gender, race, source of admission, and year of treatment (odds ratio 3.5 for adverse events surgery vs. endovascular therapy, 95% confidence interval 2.4–5.2, p<0.0001 by logistic regression). In-hospital deaths occurred in 3.5% of surgical cases and 0.5% of endovascular cases (p=0.003), and the difference remained significant after adjustment in multivariable models (odds ratio 6.3, 1.5–26.2, p=0.01). Adverse events were less likely at hospitals treating a larger portion of patients with endovascular therapy after adjustment for case characteristics, hospital treatment volume, and clustering of observations using generalized estimating equations (p=0.006). Conclusions. In California, endovascular repair of unruptured cerebral aneurysms is associated with fewer adverse events and in-hospital deaths than surgery.

Abstract WP19: Transfer Selection for Endovascular Therapy of Ischemic Stroke within A Collaborative Network: Off-site Versus On-site Neurology Service

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Simon M Winzer ◽  
Kristian Barlinn ◽  
Johannes Gerber ◽  
Timo Siepmann ◽  
Lars-Peder Pallesen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Functional Outcome ◽  
Endovascular Therapy ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Comprehensive Stroke Center ◽  
Favorable Functional Outcome ◽  
Selection Of Patients ◽  
Selection Of

Introduction: Selection of patients for endovascular therapy (EVT) may depend on the hospital providing first line assessment. In our collaborative stroke network, we aimed to compare clinical characteristics and outcomes in ischemic stroke patients undergoing EVT who were transferred from telestroke hospitals following teleconsultation and in those transferred from hospitals providing on-site neurology service. Methods: We analyzed prospectively collected data from consecutive ischemic stroke patients who underwent emergent EVT at our comprehensive stroke center (01/2010 to 12/2014) after acute transfer from either telestroke hospitals or non-telestroke hospitals with on-site neurology service. We compared baseline characteristics, onset-to-EVT time, symptomatic intracranial hemorrhage (sICH), favorable functional outcome (mRS 0-2) at discharge and in-hospital mortality. Results: Among 133 transferred patients who underwent emergent EVT: median age 67 years (IQR, 15); 56% men; median NIHSS score 17 (21); 52% had anterior and 48% posterior circulation stroke. Sixty-five patients (49%) were transferred from telestroke and 68 (51%) from non-telestroke hospitals. Telestroke patients were less severely affected (median NIHSS scores: 15 [7] vs. 22 [20]; p=.0005) and more likely to have anterior circulation stroke (69% vs. 35%; p<.0001) compared with non-telestroke patients. No between-group differences were present with regard to demographics, vascular risk factors, intravenous tPA rate and onset-to-EVT time. In-hospital mortality was lower among telestroke compared with non-telestroke patients (11% vs. 26%; p=.026). There were no differences in sICH (5% vs. 4%; p=1.0) and favorable functional outcome (17% vs. 18%; p=1.0). Conclusions: Patients transferred from telestroke hospitals were twice as often treated for anterior circulation stroke than those from non-telestroke neurological hospitals within our stroke network. This might be explained by more conservative selection of patients potentially amenable for EVT in hospitals harboring on-site neurology service but no EVT-capability. As our data was acquired prior to evidence from the positive EVT trials, further research is warranted to elaborate these findings.

scholarly journals Clinical Evidence of Vestibular Dysregulation in Colicky Babies Before and After Chiropractic Treatment Versus Non-Colicky Babies.

2020 ◽  
Author(s):  
Jan Hoeve
Keyword(s):  
Clinical Diagnosis ◽  
Odds Ratio ◽  
Clinical Evidence ◽  
Infantile Colic ◽  
Chiropractic Treatment ◽  
Clinical Index ◽  
Behavioral Expression ◽  
Before And After ◽  
The Mean ◽  
The Difference

Abstract BackgroundAfter 65 years of research that has been primarily directed at differentiating between normal and colicky crying, the cause of infantile colic remains elusive and no definitive cure has been found. Given the general absence of pathology, colicky crying is widely considered the extreme end of a spectrum of normal crying behavior. In the literature scattered evidence can be found suggesting that infantile colic may be the behavioral expression of physiological brainstem dysregulation, particularly of the vestibular and autonomic nuclei. The purpose of this study is to present a five-point clinical index of vestibular (hyper)activity and its application to investigate vestibular dysregulation in colicky and non-colicky babies.Methods120 consecutive colicky babies were evaluated using this index, before and after a very gentle vibratory treatment, and compared to 117 non-colicky babies.ResultsBefore treatment, of 120 colicky babies only 2 (1.7%) scored 0, whereas 118 (98.3%) scored scored 1-5. Of 117 non-colicky babies 89 (76,1%) scored 0 and 28 (23.9%) scored 1-3, none scored 4-5. The odds ratio is OR (CI 95%) 187.54 (43.52-808.09). After treatment 111 (92.5%) scored 0 and 9 (7.5%) scored 1-3, none scored 4-5. A McNemar test showed the difference before and after to be significant (χ² = 109.00, p < .001). For colicky babies the mean vestibular score is 2.88(SD 1.22), compared to 0.37(SD 0.73) for non-colicky babies, a difference of 87.2%. After treatment the score decreased from 2.88 (SD 1.12) to 0.10 (SD 0.40), or 96.5%. ConclusionColicky babies are not just infants who cry a lot. They also show clinical evidence of vestibular dysregulation. Gentle treatment aimed at relaxing tight sub-occipital musculature by means of a vibrational technique may be effective in decreasing vestibular hyperactivity, signifying an improvement in brainstem regulation. The vestibular index opens the prospect for development into a tool towards an objective and practical clinical diagnosis of infantile colic.

scholarly journals Posttreatment Ischemic Lesion Evolution Is Associated With Reduced Favorable Functional Outcome in Patients With Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Praneeta Konduri ◽  
Henk van Voorst ◽  
Amber Bucker ◽  
Katinka van Kranendonk ◽  
Anna Boers ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Interaction Analysis ◽  
Univariate Analysis ◽  
Arterial Occlusion ◽  
Lesion Volume ◽  
Ischemic Lesion ◽  
Favorable Functional Outcome

Background and Purpose: Ischemic lesion volume can increase even 24 hours after onset of an acute ischemic stroke. In this study, we investigated the association of lesion evolution with functional outcome and the influence of successful recanalization on this association. Methods: We included patients from the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) who received good quality noncontrast CT images 24 hours and 1 week after stroke onset. The ischemic lesion delineations included infarct, edema, and hemorrhagic transformation. Lesion evolution was defined as the difference between the volumes measured on the 1-week and 24-hour noncontrast CTs. The association of lesion evolution with functional outcome was evaluated using unadjusted and adjusted logistic regression. Adjustments were made for baseline, clinical, and imaging parameters that were associated P <0.10) in univariate analysis with favorable functional outcome, defined as modified Rankin Scale score of ≤2. Interaction analysis was performed to evaluate the influence of successful recanalization, defined as modified Arterial Occlusion Lesion score of 3 points, on this association. Results: Of the 226 patients who were included, 69 (31%) patients achieved the favorable functional outcome. Median lesion evolution was 22 (interquartile range, 10–45) mL. Lesion evolution was significantly inversely correlated with favourable functional outcome: unadjusted odds ratio, 0.76 (95% CI, 0.66–0.86; per 10 mL of lesion evolution; P <0.01) and adjusted odds ratio: 0.85 (95% CI, 0.72–0.97; per 10 mL of lesion evolution; P =0.03). There was no significant interaction of successful recanalization on the association of lesion evolution and favorable functional outcome (odds ratio, 1.01 [95% CI, 0.77–1.36]; P =0.94). Conclusions: In our population, subacute ischemic lesion evolution is associated with unfavorable functional outcome. This study suggests that even 24 hours after onset of stroke, deterioration of the brain continues, which has a negative effect on functional outcome. This finding may warrant additional treatment in the subacute phase.

scholarly journals Clinical Evidence of Vestibular Dysregulation in Colicky Babies Before and After Chiropractic Treatment vs. Non-colicky Babies

2021 ◽  
Vol 9 ◽  
Author(s):  
Jan Hoeve
Keyword(s):  
Clinical Diagnosis ◽  
Odds Ratio ◽  
Clinical Evidence ◽  
Infantile Colic ◽  
Chiropractic Treatment ◽  
Behavioral Expression ◽  
Vibrational Stimulation ◽  
Before And After ◽  
The Mean ◽  
The Difference

Background: To date, after 65 years of research that was primarily directed at differentiating between normal and colicky crying, the cause of infantile colic remains elusive and no definitive cure has been found. Given the general absence of pathology, colicky crying is widely considered the extreme end of a spectrum of normal crying behavior. However, evidence gleaned from scattered sources throughout the literature suggests that infantile colic may be the behavioral expression of physiological brainstem dysregulation, particularly of the vestibular and autonomic systems. The purpose of this study is to present a five-point clinical index of vestibular (hyper) activity and its application to investigate vestibular dysregulation in colicky and non-colicky babies.Methods: One hundred and twenty consecutive colicky babies were evaluated using this index, before and after a very gentle vibratory treatment, and compared to 117 non-colicky babies.Results: Before treatment, of 120 colicky babies only 2 (1.7%) scored 0, whereas 118 (98.3%) scored 1–5. Of 117 non-colicky babies 89 (76.1%) scored 0 and 28 (23.9%) scored 1–3, none scored 4–5. The odds ratio is OR (CI 95%) 187.54 (43.52–808.09). After treatment 111 (92.5%) scored 0 and 9 (7.5%) scored 1–3, none scored 4–5. A McNemar test showed the difference before and after to be significant (χ2 = 109.00, p &lt; 0.001). For colicky babies the mean vestibular score is 2.88 (SD 1.22), compared to 0.37 (SD 0.73) for non-colicky babies, a difference of 87.2%. After treatment the score decreased from 2.88 (SD 1.12) to 0.10 (SD 0.40), or 96.5%.Conclusion: Colicky babies are not just infants who cry a lot. They also show clinical evidence of vestibular dysregulation. Treatment aimed at relaxing tight sub-occipital musculature by means of gentle vibrational stimulation may be effective in decreasing vestibular hyperactivity, signifying an improvement in brainstem regulation. The vestibular index opens the prospect for development into a tool toward an objective and practical clinical diagnosis of infantile colic.

Thrombectomy With and Without Computed Tomography Perfusion Imaging in the Early Time Window: A Pooled Analysis of Patient-Level Data

Stroke ◽  
2021 ◽  
Author(s):  
Ashutosh P. Jadhav ◽  
Mayank Goyal ◽  
Johanna Ospel ◽  
Bruce C. Campbell ◽  
Charles B.L.M. Majoie ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Time Window ◽  
Early Time ◽  
Computed Tomography Perfusion ◽  
Patient Level Data ◽  
Patient Level ◽  
Good Functional Outcome ◽  
Level Data

Background and Purpose: The optimal imaging paradigm for endovascular thrombectomy (EVT) patient selection in early time window (0–6 hours) treated acute ischemic stroke patients remains uncertain. We aimed to compare post-EVT outcomes between patients who underwent prerandomization basic (noncontrast computed tomography [CT], CT angiography only) versus additional advanced imaging (computed tomography perfusion [CTP] imaging) and to determine the association of performance of prerandomization CTP imaging with clinical outcomes. Methods: The HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) pooled patient-level data from randomized controlled trials comparing EVT with usual care for acute ischemic stroke due to anterior circulation large vessel occlusion. Good functional outcome, defined as modified Rankin Scale score 0 to 2 at 90 days, was compared between randomized patients with and without CTP baseline imaging. Univariable and multivariable binary logistic regression analysis was performed to determine the association of baseline CTP imaging and good functional outcome. Results: We analyzed 1348 patients 610 (45.3%) of whom underwent CTP prerandomization. The benefit of EVT compared with best medical management was maintained irrespective of the baseline imaging paradigm (90-day modified Rankin Scale score 0–2 in EVT versus control patients: with CTP: 46.0% (137/298) versus 28.9% (88/305), without CTP: 44.1% (162/367) versus 27.3% (100/366). Performance of CTP baseline imaging compared with baseline noncontrast CT and CT angiography only yielded similar rates of good outcome (odds ratio, 1.05 [95% CI, 0.82–1.33], adjusted odds ratio, 1.04, [95% CI, 0.80–1.35]). Conclusions: Rates of good functional outcome were similar among patients in whom CTP was or was not performed, and EVT treatment effect in the 0- to 6-hour time window was similar in patients with and without baseline CTP imaging.

Abstract WMP5: Endovascular Therapy Stroke Outcome in Very Elderly: Meta-analysis

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Michelle P Lin ◽  
David S Liebeskind ◽  
Steven Cen ◽  
William J Mack ◽  
Arun P Amar ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Elderly Patients ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Endovascular Therapy ◽  
Odds Ratio ◽  
Age Groups ◽  
Large Vessel ◽  
Very Elderly

Introduction: Very elderly (age ≥80yo) individuals account for about one-third of all stroke admissions with mixed literature demonstrating relative poor stroke outcomes. With overwhelming recent evidence supporting the use of intra-arterial thrombectomy in addition to IV thrombolysis for large-vessel occlusive stroke, we conducted a metaanalysis to assess long-term functional outcome following mechanical thrombectomy in very elderly. Hypothesis: Very elderly patients with acute ischemic stroke treated with thrombectomy have equally favorable long-term functional outcomes to their younger counterparts Methods: Stroke endovascular trials published in New England Journal of Medicine 2014-2015 were included if they reported odds ratio of good functional outcome (improvement in modified Rankin score, mRS) comparing thrombectomy vs IV-tPA dichotomized by age groups (age ≤ 80yo vs >80yo, 2 studies dichotomized age at 70yo). Multivariate adjusted odds ratios and the corresponding standard errors were used for the metaanalysis. Pooled odds ratio estimates across trials were synthesized by using a random-effects model based on Mantel-Haenszel methods. The pooled estimates with 95% confidence interval were compared between elderly and younger age groups. Forest plots constructed. Results: Of the 5 recent intraartrial thrombectomy trials, 4 studies reported subgroup analysis by age with 1,206 participants, 28% (N=334) were above the age of 80yo, 72% (N=872) were ≤80yo. Among very elderly patients undergoing thrombectomy, the pooled odds ratio of good functional outcome at 3 months was 1.91 (1.13-3.24), in the younger group the pooled odds ratio was 1.95 (1.50-2.53). Conclusions: Endovascular therapy was an effective therapy for very elderly individuals presenting with acute ischemic stroke caused by large vessel occlusive disease. Future studies are needed to further assess the safety and effectiveness of thrombectomy in this growing population.

scholarly journals Efficacy and Safety of Adherence to dl-3-n-Butylphthalide Treatment in Patients With Non-disabling Minor Stroke and TIA—Analysis From a Nationwide, Multicenter Registry

2021 ◽  
Vol 12 ◽  
Author(s):  
Zefeng Tan ◽  
Yin Zhao ◽  
Wanyong Yang ◽  
Shenwen He ◽  
Yan Ding ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Confidence Interval ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Functional Outcomes ◽  
Adjusted Odds Ratio ◽  
Efficacy And Safety ◽  
Stroke Patients ◽  
Minor Ischemic Stroke ◽  
Favorable Functional Outcome

Background: Dl-3-n-Butylphthalide (NBP) has the potential to improve clinical outcomes in acute ischemic stroke patients by improving collateral circulation. We aimed to evaluate the efficacy and safety of NBP in patients with non-disabling minor ischemic stroke and transient ischemic attack (TIA).Methods: The BRIDGE (the observation study on clinical effectiveness of NBP on patients with non-disabling ischemic cerebrovascular disease) is a prospective registry to monitor the efficacy and safety of NBP therapy in acute non-disabling ischemic stroke or high-risk TIA. Non-disabling minor ischemic stroke patients within 48 h were enrolled across 51 stroke centers in China. We divided patients into NBP compliance or non-compliance groups according to their adherence to NBP. The primary outcome was the favorable functional outcome at 90 days, defined as a modified Rankin scale (mRS) &lt;2.Results: Between 10th October 2016 and 25th June 2019, 3,118 patients were included in this analysis. In multivariable analysis, after adjusting for common risk factors and demographic factors, NBP-compliance group has a higher proportion of favorable functional outcome (92.1 vs. 87.4%, adjusted odds ratio 2.00, 95% confidence interval, 1.50–2.65), and a higher stroke recurrence rate (2.40 vs. 0.31%, adjusted odds ratio 8.86, 95% confidence interval, 3.37–23.30) than the NBP-non-compliance group. There was no significant difference in death and intracranial hemorrhage rate between the two groups. In subgroup analysis, patients with National Institutes of Health Stroke Scale (NIHSS) scores from 3 to 5 who complied to NBP therapy had a higher rate of favorable functional outcomes than the NBP-non-compliance group. [89.8 vs. 76.8%, adjusted odds ratio 2.54 (1.64–3.93), adjusted interaction P = 0.001].Conclusion: In non-disabling minor ischemic stroke or TIA patients, compliance with NBP therapy led to better 90-day functional outcomes despite a higher risk of recurrence, and this effect seems to be stronger in patients with NIHSS scores of 3–5. Further large randomized, double-blind controlled studies to analyse the association between NBP and functional outcome is warranted in the coming future.

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