Mortalité chez les patients traités par traitement thrombolytique par voie intraveineuse (rt-PA) pour une ischémie cérébrale aiguë (causes, délais et facteurs prédictifs)

CONTEXTE : la thrombolyse par voie intraveineuse (iv) ne réduit pas sensiblement la mortalité des patients traités dans le cadre d une ischémie cérébrale aiguë. Le taux de mortalité de ces patients varie de 10 à 20% à 3 mois selon l'âge et la sévérité clinique initiale. OBJECTIF: déterminer le délai, les causes et les facteurs prédictifs de décès chez les patients thrombolysés iv par rt-PA dans le cadre d'une ischémie cérébrale aiguë. METHODE: Nous avons effectué une analyse de données recueillies de façon prospective chez des patients consécutifs traités par rt-PA iv pour une ischémie cérébrale aiguë à l'hôpital Universitaire de Lille. RESULTATS: parmi 500 patients (246 hommes, âge médian 71 ans, NIHSS médian 12, médiane de délai de traitement par rapport au début des symptômes neurologiques 148 minutes), 76 (15,2%) sont décédés dans les trois premiers mois du suivi. Vingt-et-un (72,4%) parmi les 29 patients morts précocement (dans les 7 jours), sont décédés des suites de complications neurologiques. Vingt-quatre (51,1%) parmi les 47 patients morts tardivement (entre 8 jours et 3 mois) sont décédés des suites d'une infection (pneumopathie chez 20 patients) et tous ces patients sauf un avaient un score de 4 ou 5 à l échelle de Rankin modifiée à 7 jours. Les facteurs prédictifs indépendants de mortalité précoce étaient la survenue de complications neurologiques aiguës et un antécédent d accident ischémique transitoire dans les 7 jours précédant l ischémie cérébrale aiguë. Les facteurs prédictifs indépendants de mortalité tardive étaient l'état clinique préexistant des patients et la survenue d infections. CONCLUSION: les complications neurologiques précoces sont les principales causes de mort précoce et tardive chez les patients thrombolysés iv par rt-PA pour une ischémie cérébrale aiguë. Les infections sont la cause la plus importante de mort tardive, mais elles se produisent chez des patients présentant une dépendance sévère. La clé pour améliorer la survie des patients thrombolysés réside donc dans le fait d améliorer leur état neurologique. A l heure actuelle, cela n est possible qu en réduisant les délais de traitement.LILLE2-BU Santé-Recherche (593502101) / SudocSudocFranceF

Predictors of Parenchymal Hematoma After Mechanical Thrombectomy

International audienceBackground and Purpose— Parenchymal hematoma (PH) is a rare but dreadful complication of acute ischemic stroke with unclear underlying mechanisms. We aimed to study the incidence and predictors of PH after mechanical thrombectomy. Methods— Data from a prospective observational multicenter registry was screened to identify acute ischemic stroke patients with an anterior circulation large vessel occlusion who underwent mechanical thrombectomy. Clinical, imaging, and procedural characteristics were used for the analysis, including brain imaging systematically performed at 24 hours. PH occurrence was assessed according to ECASS (European Collaborative Acute Stroke Study) criteria. Univariate and multivariable analyses were performed to identify predictors of PH. Results— A total of 1316 patients were included in the study. PH occurred in 153 out of 1316 patients (11.6%) and was associated with a lower rate of favorable outcome and increased mortality. On multivariable analysis, age (per 1 year increase, odds ratio [OR], 1.01; 95% CI, 1.00–1.03; P =0.05), current smoking (OR, 2.02; 95% CI, 1.32–3.09; P <0.01), admission Alberta Stroke Program Early CT Score (per a decrease of 1 point, OR, 1.70; 95% CI, 1.18–2.44; P <0.01), general anesthesia (OR, 1.98; 95% CI, 1.36–2.90; P <0.001), angiographic poor collaterals (OR, 2.13; 95% CI, 1.36–3.33; P <0.001) and embolization in new territory (OR, 2.94; 95% CI, 1.70–5.10; P <0.001) were identified as independent predictors of PH. Conclusions— PH occurred at a rate of 11.6% after mechanical thrombectomy, with high morbidity and mortality. Our study identified clinical, radiological, and procedural predictors of PH occurrence that can serve as the focus of future periprocedural management studies with the aim of reducing its occurrence. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT03776877

Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data

Background: General anaesthesia (GA) during endovascular thrombectomy has been associated with worse patient outcomes in observational studies compared with patients treated without GA. We assessed functional outcome in ischaemic stroke patients with large vessel anterior circulation occlusion undergoing endovascular thrombectomy under GA, versus thrombectomy not under GA (with or without sedation) versus standard care (ie, no thrombectomy), stratified by the use of GA versus standard care. Methods: For this meta-analysis, patient-level data were pooled from all patients included in randomised trials in PuMed published between Jan 1, 2010, and May 31, 2017, that compared endovascular thrombectomy predominantly done with stent retrievers with standard care in anterior circulation ischaemic stroke patients (HERMES Collaboration). The primary outcome was functional outcome assessed by ordinal analysis of the modified Rankin scale (mRS) at 90 days in the GA and non-GA subgroups of patients treated with endovascular therapy versus those patients treated with standard care, adjusted for baseline prognostic variables. To account for between-trial variance we used mixed-effects modelling with a random effect for trials incorporated in all models. Bias was assessed using the Cochrane method. The meta-analysis was prospectively designed, but not registered. Findings: Seven trials were identified by our search; of 1764 patients included in these trials, 871 were allocated to endovascular thrombectomy and 893 were assigned standard care. After exclusion of 74 patients (72 did not undergo the procedure and two had missing data on anaesthetic strategy), 236 (30%) of 797 patients who had endovascular procedures were treated under GA. At baseline, patients receiving GA were younger and had a shorter delay between stroke onset and randomisation but they had similar pre-treatment clinical severity compared with patients who did not have GA. Endovascular thrombectomy improved functional outcome at 3 months both in patients who had GA (adjusted common odds ratio (cOR) 1·52, 95% CI 1·09–2·11, p=0·014) and in those who did not have GA (adjusted cOR 2·33, 95% CI 1·75–3·10, p&lt;0·0001) versus standard care. However, outcomes were significantly better for patients who did not receive GA versus those who received GA (covariate-adjusted cOR 1·53, 95% CI 1·14–2·04, p=0·0044). The risk of bias and variability between studies was assessed to be low. Interpretation: Worse outcomes after endovascular thrombectomy were associated with GA, after adjustment for baseline prognostic variables. These data support avoidance of GA whenever possible. The procedure did, however, remain effective versus standard care in patients treated under GA, indicating that treatment should not be withheld in those who require anaesthesia for medical reasons