Anemia Predicts Poor Clinical Outcome in Mechanical Thrombectomy Patients with Fair or Good Collateral Circulation

Background and Purpose: Anemia predicts poor clinical outcome of ischemic stroke in the general stroke population. We studied whether this applies to those treated with mechanical thrombectomy for proximal anterior circulation occlusion in the setting of differing collateral circulation. Methods: We collected the data of 347 consecutive anterior circulation stroke patients who underwent mechanical thrombectomy after multimodal CT imaging in a single tertiary stroke care center. Patients with occlusion of the internal carotid artery and/or the first segment of the middle cerebral artery were included. We recorded baseline clinical, laboratory, procedural, and imaging variables, and the technical, imaging, and clinical outcomes. Differences between anemic and nonanemic patients were studied with appropriate statistical tests and binary logistic regression analysis. Results: Ninety-four out of the 285 patients eligible for analysis had anemia, and 243 had fair or good collateral circulation (collateral score, CS, >0). Fifty-four percent of the patients experienced good 3-month clinical outcome (modified Rankin Scale ≤2). In pooled analyses of the CS 1-4 and 2-4 ranges, nonanemic patients had good clinical outcome significantly more often (p < 0.001 for both). This effect was not seen in patients with poor collateral circulation (CS = 0). Nonanemic patients had significantly better odds of good clinical outcome (OR = 2.6, 95% CI 1.377-5.030, p = 0.004) in a binary regression model. A 0.1 g/dL increase in hemoglobin improved the odds of good clinical outcome by 2% (OR = 1.02, 95% CI 1.002-1.044, p = 0.03). Conclusions: Low hemoglobin on admission predicts poor clinical outcome in mechanical thrombectomy patients with fair or good collateral circulation.publishedVersionPeer reviewe

Finnish flow diverter study : 8 years of experience in the treatment of acutely ruptured intracranial aneurysms

Background Flow diversion of acutely ruptured intracranial aneurysms (IAs) is controversial due to high treatment-related complication rates and a lack of supporting evidence. We present clinical and radiological results of the largest series to date. Methods This is a nationwide retrospective study of acutely ruptured IAs treated with flow diverters (FDs). The primary outcome was the modified Rankin Scale (mRS) score at the last available follow-up time. Secondary outcomes were treatment-related complications and the aneurysm occlusion rate. Results 110 patients (64 females; mean age 55.7 years; range 12-82 years) with acutely ruptured IAs were treated with FDs between 2012 and 2020 in five centers. 70 acutely ruptured IAs (64%) were located in anterior circulation, and 47 acutely ruptured IAs (43%) were blister-like. A favorable functional outcome (mRS 0-2) was seen in 73% of patients (74/102). Treatment-related complications were seen in 45% of patients (n=49). Rebleeding was observed in 3 patients (3%). The data from radiological follow-ups were available for 80% of patients (n=88), and complete occlusion was seen in 90% of aneurysms (79/88). The data from clinical follow-ups were available for 93% of patients (n=102). The overall mortality rate was 18% (18/102). Conclusions FD treatment yields high occlusion for acutely ruptured IAs but is associated with a high risk of complications. Considering the high mortality rate of aneurysmal subarachnoid hemorrhage, the prevention of rebleeding is crucial. Thus, FD treatment may be justified as a last resort option.Peer reviewe

Finnish flow diverter study : 8 years of experience in the treatment of acutely ruptured intracranial aneurysms

Background Flow diversion of acutely ruptured intracranial aneurysms (IAs) is controversial due to high treatment-related complication rates and a lack of supporting evidence. We present clinical and radiological results of the largest series to date. Methods This is a nationwide retrospective study of acutely ruptured IAs treated with flow diverters (FDs). The primary outcome was the modified Rankin Scale (mRS) score at the last available follow-up time. Secondary outcomes were treatment-related complications and the aneurysm occlusion rate. Results 110 patients (64 females; mean age 55.7 years; range 12-82 years) with acutely ruptured IAs were treated with FDs between 2012 and 2020 in five centers. 70 acutely ruptured IAs (64%) were located in anterior circulation, and 47 acutely ruptured IAs (43%) were blister-like. A favorable functional outcome (mRS 0-2) was seen in 73% of patients (74/102). Treatment-related complications were seen in 45% of patients (n=49). Rebleeding was observed in 3 patients (3%). The data from radiological follow-ups were available for 80% of patients (n=88), and complete occlusion was seen in 90% of aneurysms (79/88). The data from clinical follow-ups were available for 93% of patients (n=102). The overall mortality rate was 18% (18/102). Conclusions FD treatment yields high occlusion for acutely ruptured IAs but is associated with a high risk of complications. Considering the high mortality rate of aneurysmal subarachnoid hemorrhage, the prevention of rebleeding is crucial. Thus, FD treatment may be justified as a last resort option.Peer reviewe

Response to letter on use of functional imaging by 11C-metomidate PET for primary aldosteronism subtyping

Non peer reviewe

Factors Affecting the Outcome of Mechanical Thrombectomy in Stroke

Äkillinen aivoverenkierron häiriöstä johtuva aivokudoksen hapenpuute on vakava tila, joka hoitamattomana johtaa aivokudoksen kuolemaan eli aivoinfarktiin. Aivoinfarkti voi aiheuttaa hankalia neurologisia puutosoireita tai jopa kuoleman. Aivoinfarkti on Suomessa ja muissa länsimaissa merkittävin yksittäinen laadukkaiden elinvuosien vähentäjä sekä yksi yleisimmistä kuolinsyistä. Tavallisimmin aivoverenkierron häiriö aiheutuu veritulpasta eli trombista, joka estää normaalin verenkierron aivokudokseen. Merkittävin hoitokeino aivoinfarktin kehittymisen välttämiseksi on verenkierron riittävän nopea palauttaminen avaamalla tukkeutunut suoni. Aikaisemmin tukoksen aukaisuun käytettiin ainoastaan laskimonsisäisesti annettua trombin liuotushoitoa, trombolyysiä. Viimeisen vuosikymmenen aikana valtimonsisäiset trombin poistomenetelmät, eli mekaaninen trombektomia, ovat kuitenkin kehittyneet merkittävästi. Erityisesti suurten kaula- ja aivovaltimotrombien poistossa mekaaniset menetelmät ovat osoittautuneet ylivertaisiksi pelkkään liuotushoitoon verrattuna. Tämän väitöskirjatutkimuksen tavoitteena oli selvittää mekaanisella trombektomialla hoidettujen potilaiden toipumiseen vaikuttavia tekijöitä. Tutkimusaineisto koostuu yli 400:sta vuosina 2013-2019 Tampereen yliopistollisessa sairaalassa trombektomialla hoidetusta aivohalvauspotilaasta. Sairaalaan tulovaiheen tilanne arvioitiin aivojen ja kaulasuonten tietokonekuvausten sekä potilastietojärjestelmästä kerättyjen tietojen pohjalta. Toimenpiteen onnistuminen määritettiin trombektomian yhteydessä tapahtuvan suonensisäisen kuvauksen perusteella. Vuorokauden kuluttua toimenpiteen jälkeen aivojen tilanne selvitettiin tietokonekuvauksella, josta arvioitiin mahdollisen infarktin kehittyminen sekä toimenpiteeseen mahdollisesti liittyvät verenvuotokomplikaatiot. Kolmen kuukauden kohdalla neurologi arvioi potilaiden toipumisen ja omatoimisuusasteen, joihin liittyvät tiedot kerättiin potilastietojärjestelmästä. Kolmen kuukauden omatoimisuusastetta käytettiin toipumistuloksen ensisijaisena mittarina. Yli 60-vuotiailla potilailla krooniset aivoverenkiertoperäiset vauriot heikensivät selvästi potilaiden omatoimisuusastetta ja lisäsivät kuolleisuutta. Potilailla, joilla näitä kroonisia vaurioita ei ollut, oli tutkimuksessamme 3,7-kertainen todennäköisyys saavuttaa hyvä omatoimisuusaste kolmen kuukauden kohdalla verrattuna potilaisiin, joilla näitä vaurioita oli havaittavissa. Potilailla, joilla todettiin merkittävä kaulasuonen ahtauma, todettiin sairaalaan tulovaiheen tietokonekuvauksessa neljä kertaa todennäköisemmin erittäin hyvät kallonsisäiset valtimokollateraalisuonet verrattuna potilaisiin, joilla ei ollut merkittävää kaulasuonen ahtaumaa. Ahtautuneen tai tukkeutuneen kaulasuonen läpi suoritetut toimenpiteet kestivät selvästi pidempään (41 min vs. 29 min potilailla, joilla ei ollut merkittävää ahtaumaa). Keskimäärin hyvän omatoimisuusasteen kolmen kuukauden kohdalla saavutti trombektomian jälkeen 54 % potilaista, eikä kaulasuonen merkittävällä ahtaumalla todettu olevan tähän tilastollisesti merkittävää vaikutusta. Anemiasta kärsivien potilaiden kuntoutuminen oli selvästi heikompaa verrattuna potilaisiin, joilla anemiaa ei todettu. Sairastetun, trombektomialla hoidetun aivoinfarktin jälkeen hyvä omatoimisuus kolmen kuukauden kohdalla oli yli 2,5 kertaa todennäköisempää, jos potilaalla ei ollut anemiaa. Hemoglobiiniarvon nousu yhdellä grammalla litraa kohden paransi hyvän lopputuloksen todennäköisyyttä kahdella prosentilla. Parempi ennuste havaittiin potilailla, joilla oli todettavia kallonsisäisiä valtimokollateraaleja. Kollateraalisuonten puuttuessa hyvän kuntoutumisen todennäköisyys oli pienempi veren hemoglobiinitasosta riippumatta. Mikäli suuren suonen tukoksesta johtuvaa äkillistä aivoverenkiertohäiriötä sairastava potilas pääsi välittömästi sairaalaan saapumisen jälkeen trombektomiaan, erinomaisen kuntoutumisen todennäköisyys oli kolminkertainen, jos hänelle ei annettu edeltävästi trombolyysiä. Minimaalisen sairaalansisäisen viiveen toimintamallilla hoidetulla potilasryhmällä trombolyysihoito 2,6-kertaisti huonomman omatoimisuusasteen todennäköisyyden kolmen kuukauden kohdalla. Lisäksi tässä potilasryhmässä havaittiin myös viitettä trombolyysin aiheuttamasta kuolleisuuden lisääntymisestä.Acute brain ischaemia due to an obstructed blood vessel in cerebral circulation is a serious condition that, without efficient treatment, can lead to a cerebral infarction, severe disability or even death. In Finland and elsewhere in the Western world, ischaemic stroke is one of the major causes of death and the main reason for losing quality-adjusted life years. Most often, ischaemic stroke is caused by a thrombus that obstructs brain circulation. The only treatment for a cerebral infarction is to restore blood flow quickly enough. Previously, the only approved treatment was intravenous thrombolysis. Over the past decade, intra-arterial mechanical thrombus removal methods have evolved significantly. Particularly, mechanical intra-arterial methods for removing occlusions caused by thrombi of the larger arteries have proven to be superior to thrombolysis therapy alone. This thesis focuses on factors affecting the outcome of mechanical thrombectomy (MT) in patients suffering an acute anterior circulation ischaemic stroke caused by a large vessel occlusion. We analysed over 400 thrombectomy patients admitted to Tampere University Hospital between 2013 and 2019. Their status at admission was evaluated with standard clinical and laboratory parameters, as well as computed tomography (CT) and CT angiography (CT-A) of the brain and neck vessels. These data were collected from patient records. The technical success of the thrombectomy intervention was evaluated from the final DS-A runs of the intervention. -A control head CT was acquired a day after the MT to evaluate possible infarct and haemorrhagic complications. The clinical outcome was determined with the modified Rankin Score (mRS) three months after the MT and used as the clinical endpoint. In our study, MT patients aged 60 years and older with pre-stroke chronic ischaemic lesions (CILs) experienced significantly increased dependency and elevated mortality after the procedure. Patients without CILs were 3.7 times more likely to achieve a good three-month clinical outcome, when compared with patients with CILs. Patients with severe carotid stenosis were four times more likely to have very good intracranial collateral circulation in an admission CT-A than patients with no or slight carotid stenosis. On the other hand, the MT intervention lasted significantly longer in patients with severe carotid stenosis (41 min, compared to 29 min in patients without severe stenosis). At three months, 54% of the patients achieved a good clinical outcome, with the severity of carotid stenosis having no significant effect. The prognosis of anaemic MT patients was significantly weaker than that of non- anaemic patients. After the MT, non-anaemic patients had over 2.5 times better odds of achieving a good three-month clinical outcome. A 0.1 g/dl increase in haemoglobin improved the odds of a good clinical outcome by 2%. The effect of anaemia was seen only in patients with intracranial collaterals. If the collateral status was poor, the odds of a good clinical outcome were lower irrespective of the blood haemoglobin level. The patients who could be transferred to MT immediately after diagnosis had significantly better odds of an excellent clinical outcome (mRS 0 or 1) if intravenous thrombolysis was not administered. In this setting of a minimal in-hospital delay, the patients who were administered thrombolysis had 2.6-fold higher odds of a poorer clinical outcome at three months. An excellent clinical outcome was three times more frequent in patients who did not receive thrombolysis. A trend of more deaths was found among the thrombolysis-treated patients

In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting

Purpose: Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods: We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results: Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions: MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients.publishedVersionPeer reviewe

Preoperative White Matter Lesions Are Independent Predictors of Long-Term Survival after Internal Carotid Endarterectomy

Background: Cerebral white matter lesions (WMLs) predict long-term survival of conservatively treated acute stroke patients with etiology other than carotid stenosis. In carotid endarterectomy patients, WMLs are associated with severe carotid stenosis and unstable plaques, with the risk of perioperative complications and with increased 30-day perioperative risk of death. However, no data exist on their effect on postoperative long-term survival, a factor important when considering the net benefit from carotid endarterectomy. Whether this effect is independent of classical risk factors and indications for surgery is not known either. We hypothesized that WMLs could be evaluated from preoperative routine computed tomography (CT) scans and are predictors of postoperative survival, independent of classical cardiovascular risk factors, indication category and degree of carotid stenosis. Methods: A total of 353 of 481 (73.4%) consecutive patients subjected to carotid endarterectomy due to different indications, i.e. asymptomatic stenosis (n = 28, 7.9%), amaurosis fugax (n = 52, 14.7%), transient ischemic attack (n = 135, 38.2%) or ischemic stroke (n = 138, 39.1%), from prospective vascular registries during the years 2001-2010 with digital preoperative CT scans, were included in the study. WMLs were rated by a radiologist (Wahlund criteria) in a blinded fashion. Internal carotid artery (ICA) stenoses were angiographically graded (Results: WML severity could be assessed with a substantial intraobserver agreement (Spearman's rho 0.843, p Conclusions: WMLs in a preoperative CT scan provide a substantially reliable estimate of postoperative long-term survival of carotid endarterectomy patients independent of currently used criteria, i.e. cardiovascular risk factors, indication category and degree of ipsilateral ICA stenosis

Association between Oral Pathology, Carotid Stenosis, and Oral Bacterial DNA in Cerebral Thrombi of Patients with Stroke

Background and purpose. Risk of acute ischemic stroke has been associated with carotid artery atherosclerosis as well as with periodontal disease. We studied whether oral pathology or carotid atherosclerosis was associated with the presence and quantity of bacterial DNA in their aspirated thrombi. Methods. Thrombus aspirates and control arterial blood were taken from 71 patients (70.4% male; mean age, 67.4 years) with acute ischemic stroke. Tooth pathology was registered using CT scans. Carotid stenosis was estimated with CTA and ultrasonography. The presence of bacterial DNA from aspirated thrombi was determined using quantitative PCR. We also analyzed the presence of these bacterial DNAs in carotid endarterectomies from patients with peripheral arterial disease. Results. Bacterial DNA was found in 59 (83.1%) of the thrombus aspirates (median, 8.6-fold). Oral streptococcal DNA was found in 56 (78.9%) of the thrombus aspirates (median, 5.1-fold). DNA from A. actinomycetemcomitans and P. gingivalis was not found. Most patients suffered from poor oral health and had in median 19.0 teeth left. Paradoxically, patients with better oral health had more oral streptococcal DNA in their thrombus than the group with the worst pathology (p=0.028). There was a trend (OR 7.122; p=0.083) in the association of ≥50% carotid artery stenosis with more severe dental pathology. Oral streptococcal DNA was detected in 2/6 of carotid endarterectomies. Conclusions. Stroke patients had poor oral health which tended to associate with their carotid artery stenosis. Although oral streptococcal DNA was found in thrombus aspirates and carotid endarterectomy samples, the amount of oral streptococcal DNA in thrombus aspirates was the lowest among those with the most severe oral pathology. These results suggest that the association between poor oral health and acute ischemic stroke is linked to carotid artery atherosclerosis.publishedVersionPeer reviewe