11 research outputs found
Detrimental effect of anemia after mechanical thrombectomy on functional outcome in patients with ischemic stroke
BackgroundAnemia can occur due to an aspiration maneuver of blood with thrombi during mechanical thrombectomy (MT) for stroke. However, the association between postoperative anemia and stroke outcomes is unknown.MethodsIn a registry-based hospital cohort, consecutive patients with acute ischemic stroke who underwent MT were retrospectively recruited. Patients were divided into the following three groups according to their hemoglobin (Hb) concentrations within 24âh after MT; no anemia (Hb concentrations â„13âg/dL for men andââ„â12âg/dL for women), mild anemia (Hb concentrations of 11â13âg/dL and 10â12âg/dL, respectively), and moderate-to-severe anemia (Hb concentrations <11âg/dL andâ<â10âg/dL, respectively). A 3-month modified Rankin Scale score of 0â2 indicated a favorable outcome.ResultsOf 470 patients, 166 were classified into the no anemia group, 168 into the mild anemia group, and 136 into the moderate-to-severe anemia group. Patients in the moderate-to-severe anemia group were older and more commonly had congestive heart failure than those in the other groups. Patients in the moderate-to-severe anemia group also had more device passes than those in the other groups (pâ<â0.001). However, no difference was observed in the rate of final extended thrombolysis in cerebral infarction â„2b reperfusion or intracranial hemorrhage among the groups. A favorable outcome was less frequently achieved in the moderate-to-severe anemia group than in the no anemia group (adjusted odds ratio, 0.46; 95% confidence interval, 0.26â0.81) independent of the baseline Hb concentration. A restricted cubic spline model with three knots showed that the adjusted odds ratio for a favorable outcome was lower in patients with lower Hb concentrations within 24âh after MT.ConclusionModerate-to-severe anemia within 24âh after MT is independently associated with a reduced likelihood of a favorable outcome.Clinical trial registrationhttps://www.clinicaltrials.gov, NCT02251665
Diagnostic utility of magnetic resonance imaging in isolated cortical venous thrombosis presenting with seizures and a hypercoagulable state
Isolated cortical venous thrombosis (ICVT) is an uncommon disorder that has only rarely been reported. Because of the increased use of magnetic resonance imaging (MRI) for investigating patients with new-onset seizures, ICVT, which is detectable by MRI, should be diagnosed more frequently. In this report, we describe the case of a 50-year-old woman who presented with seizures and in a hypercoagulable state. She was diagnosed with ICVT, which was detected by T2*-weighted gradient-echo MRI. It is considered that, with the increasing use of T2*-weighted gradient-echo imaging, ICVT should be diagnosed more frequently in patients presenting with seizures, especially when in combination with a hypercoagulable state. Such early diagnosis would improve these patients' outcomes. Keywords: Cerebral venous thrombosis, Magnetic resonance imaging, Seizure
Abstract Number â 209: Shortâ and longâterm outcomes of mechanical thrombectomy in acute ischemic stroke patients with active cancer
Introduction We aim to investigate the difference in mechanical thrombectomy (MT) outcome for cancerârelated stroke (CRS) with active and inactive cancer. Methods Of the consecutive acute ischemic stroke (AIS) patients admitted to our institute from 2010 to 2021, patients with cancer who received MT within 24 hours of onset and were enrolled.Outcomes including the favorable outcome (modified Rankin Scale score of 0 to 2) at3 months, 1âyear,and death within 3 months or 1âyearwere assessed between patients with active and inactive cancer among patients with cancer. The rate offirst pass effect (FPE, extendedThrombolysis in Cerebral Infarction[eTICI] 2c/3 after first pass) and final eTICI 2c/3 achievement were also assessed. Active cancer was defined as a cancer that was diagnosed within 6 months; required chemotherapy or surgical treatment within 6 months; or was recurrent, metastatic, or inoperable. Results Of 59 patients (26 women; median age, 80 years; median NIH Stroke Scale score[NIHSS] 17), 19 (32.2%) patients had an active cancer. Patients with active cancer has less atrial fibrillation (47% vs. 78%,P< 0.01) and higher medianDâdimer(4.60ÎŒg/mLvs. 2.00ÎŒg/mL,P< 0.01). There were no significant differences in the favorable outcome at 3 months (26% vs. 45%,PÂ =Â 0.26) and at 1 year (26% vs. 45%,PÂ =Â 0.26) between both groups, but death within 3 months (32% vs. 5%,P< 0.01) and within 1 year (42% vs. 8%,P< 0.01) were more frequent in patients with active cancer than those with inactive cancer. Conclusions Longâterm clinical outcomes of patients with active cancer were worse than those with inactive cancer
Mechanical Thrombectomy Beyond 2b Reperfusion: Should We Pursue a Higher Reperfusion Grade after Achievement of 2b?
Background Extended thrombolysis in cerebral infarction (eTICI) 2c/3 reperfusion after mechanical thrombectomy (MT) is associated with better stroke outcomes than eTICI 2b. Whether additional MT attempt after achieving eTICI 2b (beyond 2b attempt) leads to better outcomes is unknown. Methods Consecutive patients with acute anterior circulation stroke who achieved eTICI 2b during MT were divided into 2 groups: those who further tried MT (beyondâ2b group) and those without (nonbeyondâ2b group). The patients who directly achieved eTICI 2c/3 without experiencing 2b (directâ2c/3 group) were also studied. The outcomes included the reperfusion status, favorable outcome (3âmonth modified Rankin scale score of 0â2), neurological improvement (a â„10âpoint decrease of the National Institutes of Health Stroke Scale score from baseline or the score of 0) at 24Â hours and symptomatic intracranial hemorrhage. Results Of 308 patients, 50 were in the beyondâ2b group, 87 in the nonbeyondâ2b group, and the remaining 171 in the directâ2c/3 group. Perfusion of middle cerebral artery branches supplying the primary motor cortex was worse in the beyondâ2b than the nonbeyondâ2b group at the time of eTICI 2b (P=0.007). Favorable outcome was similarly common (48% for each, P=0.40). Neurological improvement was more frequent (52% versus 37%; P=0.04) and symptomatic intracranial hemorrhage tended to be more common (6% versus 1%, P=0.11) in the beyondâ2b than the nonbeyondâ2b group. Eighteen patients (36%) in the beyondâ2b group finally achieved eTICI 2c/3; 10 of these (56%) and 14 of the remaining 32 (44%) had favorable outcome (P=0.83). The former rate was similar to that in the directâ2c/3 group (58%; P=0.99). Conclusions Patients undergoing additional MT attempt after achieving eTICI 2b had numerically but not significantly more symptomatic intracranial hemorrhage and showed a similar level of functional outcome at 3 months than those who did not. When eTICI 2c/3 was finally achieved by additional attempts, functional outcome was similar with that of patients who directly achieved eTICI 2c/3 without experiencing 2b. Clinical Trial Registration Information URL: https://www.clinicaltrials.gov. Unique identifier: NCT02251665
Tmax Mismatch Ratio to Identify Intracranial Atherosclerotic StenosisâRelated LargeâVessel Occlusion Before Endovascular Therapy
Background We aimed to clarify which timeâtoâmaximum of the tissue residue function (Tmax) mismatch ratio is useful in predicting anterior intracranial atherosclerotic stenosis (ICAS)ârelated largeâvessel occlusion (LVO) before endovascular therapy. Methods and Results Patients with ischemic stroke who underwent perfusionâweighted imaging before endovascular therapy for anterior intracranial LVO were divided into those with ICASârelated LVO and those with embolic LVO. Tmax ratios of >10âs/>8âs, >10âs/>6âs, >10âs/>4âs, >8âs/>6âs, >8âs/>4âs, and >6âs/>4âs were considered Tmax mismatch ratios. Binominal logistic regression was used to identify ICASârelated LVO, and the adjusted odds ratio (aOR) and 95% CI for each Tmax mismatch ratio increase of 0.1 were calculated. A similar analysis was performed for ICASârelated LVO with and without embolic sources, using embolic LVO as the reference. Of 213 patients (90 women [42.0%]; median age, 79âyears), 39 (18.3%) had ICASârelated LVO. The aOR (95% CI) per 0.1 increase in Tmax mismatch ratio in ICASârelated LVO with embolic LVO as reference was lowest with Tmax mismatch ratio >10âs/>6âs (0.56 [0.43â0.73]). Multinomial logistic regression analysis also showed the lowest aOR (95% CI) per 0.1 increase in Tmax mismatch ratio with Tmax >10âs/>6âs (ICASârelated LVO without embolic source: 0.60 [0.42â0.85]; ICASârelated LVO with embolic source: 0.55 [0.38â0.79]). Conclusions A Tmax mismatch ratio of >10âs/>6âs was the optimal predictor of ICASârelated LVO compared with other Tmax profiles, with or without an embolic source before endovascular therapy. Registration clinicaltrials.gov. Identifier NCT02251665
Early initiation of rivaroxaban after reperfusion therapy for stroke patients with nonvalvular atrial fibrillation
BACKGROUND: The optimal timing of initiating oral anticoagulants after reperfusion therapy for ischemic stroke is unknown. Factors related to early initiation of rivaroxaban and differences in clinical outcomes of stroke patients with nonvalvular atrial fibrillation (NVAF) who underwent reperfusion therapy was investigated. METHODS: From data of 1,333 NVAF patients with ischemic stroke or transient ischemic attack (TIA) in a prospective multicenter study, patients who started rivaroxaban after intravenous thrombolysis and/or mechanical thrombectomy were included. The clinical outcomes included the composite of ischemic events (recurrent ischemic stroke, TIA, or systemic embolism) and major bleeding at 3 months. RESULTS: Among the 424 patients, the median time from index stroke to starting rivaroxaban was 3.2 days. On multivariable logistic regression analysis, infarct size (odds ratio [OR], 0.99; 95%CI, 0.99-1.00) was inversely and successful reperfusion (OR, 2.13; 95%CI, 1.24-3.72) was positively associated with initiation of rivaroxaban within 72 hours. 205 patients were assigned to the early group (\u3c 72 hours) and 219 patients (â„ 72 hours) to the late group. Multivariable Cox regression models showed comparable hazard ratios between the two groups at 3 months for ischemic events (hazard ratio [HR], 0.18; 95%CI, 0.03-1.32) and major bleeding (HR, 1.80; 95%CI, 0.24-13.54). CONCLUSIONS: Infarct size and results of reperfusion therapy were associated with the timing of starting rivaroxaban. There were no significant differences in the rates of ischemic events and major bleeding between patients after reperfusion therapy who started rivaroxaban \u3c 72 hours and â„ 72 hours after the index stroke. CLINICAL TRIAL REGISTRATION: Unique identifier: NCT02129920; URL: https://www.clinicaltrials.gov
Mechanical Thrombectomy Up to 24Â Hours in Large Vessel Occlusions and Infarct Velocity Assessment
Background We retrospectively compared earlyâ (<6Â hours) versus lateâ (6â24Â hours) presenting patients using perfusionâweighted imaging selection and evaluated clinical/radiographic outcomes. Methods and Results Large vessel occlusion patients treated with mechanical thrombectomy from August 2017 to July 2020 within 24Â hours of onset were retrieved from a singleâcenter database. Perfusionâweighted imaging was analyzed by automated software and final infarct volume was measured semiâautomatically within 14Â days. The primary end point was good outcome (modified Rankin Scale 0â2 at 90Â days). Secondary end points were excellent outcome (modified Rankin Scale 0â1 at 90Â days), symptomatic intracranial hemorrhage, and death. Clinical characteristics/radiological values including hypoperfusion volume and infarct growth velocity (baseline volume/onsetâtoâimage time) were compared between the groups. Of 1294 patients, 118 patients were included. The median age was 74Â years, baseline National Institutes of Health Stroke Scale score was 14, and core volume was 13Â mL. The lateâpresenting group had more female patients (67% versus 31%, respectively; P=0.001). No statistically significant differences were seen in good outcome (42% versus 53%, respectively; P=0.30), excellent outcome (26% versus 32%, respectively; P=0.51), symptomatic intracranial hemorrhage (6.5% versus 4.6%, respectively; P=0.74), and death (3.2% versus 5.7%, respectively; P=0.58) between the groups. The lateâpresenting group had more atherothrombotic cerebral infarction (19% versus 6%, respectively; P=0.03), smaller hypoperfusion volume (median: 77 versus 133Â mL, respectively; P=0.04), and slower infarct growth velocity (median: 0.6 versus 5.1Â mL/h, respectively; P=0.03). Conclusions Patients with earlyâ and lateâtime windows treated with mechanical thrombectomy by automated perfusionâweighted imaging selection have similar outcomes, comparable with those in randomized trials, but different in infarct growth velocities. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02251665
Nationwide Trends in Reperfusion Therapy and Outcomes of Acute Ischemic Stroke According to Severity: The Japan Stroke Data Bank
Background It is unclear whether all patient subgroups with acute ischemic stroke have benefited from advances in reperfusion therapy. We investigated longâterm trends of reperfusion therapy and outcomes according to the stroke severity. Methods Patients with acute ischemic stroke registered in the prospective nationwide hospitalâbased registry between 2000 and 2020 were examined. Baseline National Institutes of Health Stroke Scale (NIHSS) score â„10 and â€5 was considered to indicate possible large vessel occlusions and minor deficits, respectively. Secular changes were assessed per 5âyear cohorts (2000â2005, 2006â2010, 2011â2015, 2016â2020). Outcomes included favorable outcome (modified Rankin scale score 0â2 at discharge). Results Of 127 741 patients, NIHSS score was â„10 in 31 747 patients (24.9%), 6â9 in 17 083 patients (13.4%), and â€5 in 78 911 patients (61.8%). In patients with NIHSS score â„10, intravenous thrombolysis frequency increased from 1.6% to 26.5% between the 2000 to 2005 and 2016 to 2020 cohorts; endovascular therapy frequency increased from 2.0% to 29.8%. Favorable outcomes increased over time (adjusted odds ratio per 1âcohort, 1.254 [95% CI, 1.204â1.306]). In patients with NIHSS score 6â9, intravenous thrombolysis frequency increased from 0.5% to 16.4%, and endovascular therapy frequency increased from 1.1% to 9.0%. Favorable outcomes did not change over time (1.005 [0.966â1.046]). In patients with NIHSS score â€5, intravenous thrombolysis frequency increased from 0.2% to 5.1%, and endovascular therapy frequency increased from 0.7% to 2.8%. Favorable outcomes decreased over time (0.954 [0.931â0.978]). Conclusions Use of reperfusion therapy has increased, particularly in patients with NIHSS score â„10. Favorable outcomes significantly increased over time in patients with NIHSS score â„10 but decreased in those with NIHSS score â€5
Atrial Fibrillation Detection and Ischemic Stroke Recurrence in Cryptogenic Stroke: A Retrospective, Multicenter, Observational Study
Background Atrial fibrillation (AF) is known to be a strong risk factor for stroke. However, the risk of stroke recurrence in patients with cryptogenic stroke with AF detected after stroke by an insertable cardiac monitor (ICM) is not well known. We sought to evaluate the risk of ischemic stroke recurrence in patients with cryptogenic stroke with and without ICMâdetected AF. Methods and Results We retrospectively reviewed patients with cryptogenic stroke who underwent ICM implantation at 8 stroke centers in Japan. Cox regression models were developed using landmark analysis and timeâdependent analysis. We set the target sample size at 300 patients based on our estimate of the annualized incidence of ischemic stroke recurrence to be 3% in patients without AF detection and 9% in patients with AF detection. Of the 370 patients, 121 were found to have AF, and 110 received anticoagulation therapy after AF detection. The incidence of ischemic stroke recurrence was 4.0% in 249 patients without AF detection and 5.8% in 121 patients with AF detection (P=0.45). In a landmark analysis, the risk of ischemic stroke recurrence was not higher in patients with AF detected â€90âdays than in those without (hazard ratio, 1.47 [95% CI, 0.41â5.28]). In a timeâdependent analysis, the risk of ischemic stroke recurrence did not increase after AF detection (hazard ratio, 1.77 [95% CI, 0.70â4.47]). Conclusions The risk of ischemic stroke recurrence in patients with cryptogenic stroke with ICMâdetected AF, 90% of whom were subsequently anticoagulated, was not higher than in those without ICMâdetected AF
Abstract 1122â000009: Impact of RNF213 p.R4810K Variant on Endovascular Therapy Outcome for Acute Large Vessel Occlusion Stroke
Introduction: The ring finger protein 213 gene (RNF213) has been identified as a susceptibility gene for moyamoya disease, and the p.R4810K polymorphism as a founder variant commonly found in East Asian patients. 1  A recent large caseâcontrol study including over 46,958 Japanese subjects reported that the RNF213 p.R4810K variant was a strong risk factor for Japanese cerebral infarction: the variant was found in 5.2% of patients with nonâcardioembolic stroke and in 2.1% of healthy controls. 2  Mechanical thrombectomy (MT) is a standard treatment for acute ischemic stroke due to occlusion of the internal carotid artery and M1 segment of the middle cerebral artery, but in East Asians, about 15â25% of LVOs for which MT was performed were reportedly caused by intracranial atherosclerotic disease (ICAD). 3  RNF213 p.R4810K variant may be involved to some extent in ICADârelated LVO of Asian patients undergoing MT. In this study, we aimed to investigate the impact of RNF213 p.R4810K variant on EVT for anterior circulation LVO stroke. Methods: Of the consecutive ischemic stroke patients from 2011 to 2021 seen in our institute, patients who underwent EVT for acute occlusion of the intracranial ICA or M1 segment of MCA and signed a consent form for RNF213 genotyping were included. Outcomes were instant reâocclusion, final modified Thrombolysis in Cerebral Infarction (mTICI) â„2b reperfusion, early reâocclusion, and modified Rankin Scale (mRS) score 0â2 at 90 days. Instant reâocclusion was defined as occurrence of reâocclusion during the procedure, whereas early reâocclusion as reâocclusion detected on magnetic resonance angiography within 2 weeks after confirmation of successful reperfusion at the end of the procedure. 4 Results: Of the 277 patients (128 women [46.2%]; median age, 76 years) analyzed, 10 (3.6%) patients had the RNF213 p.R4810K variant. The variant carriers were younger (67 years vs. 76 years, P<0.01), more frequently received angioplasty (40.0% vs. 12.0%, P<0.01), and more frequently had intracranial atherosclerotic diseaseârelated LVO as a cause of acute LVO (70.0% vs. 8.6%, P<0.01) than nonâcarriers. The variant carriers showed higher rates of instant reâocclusion (40.0% vs. 5.6%, P<0.01), but there were no statistically significant interâgroup differences for the final mTICI â„2b reperfusion rate between carriers and nonâcarriers (100.0% vs. 81.6%, P = 0.22). Early reâocclusion was more frequent in the variant carriers than nonâ carriers (60.0% vs. 0.4%, P<0.01) with no intergroup difference in the rate of repeated EVT (67.7% vs. 100.0%, P = 0.71). There were no statistically significant interâgroup differences for achievement of mRS score 0â2 (60.0% vs. 51.7%, P = 0.75) Conclusions: Both instant and early reâocclusion were more frequent in the RNF213 p.R4810K variant carriers who had received EVT for acute anterior circulation LVO than in the nonâcarriers. Potential impact of RNF213 polymorphism status on EVT outcomes was clarified