Thrombectomy in large vessel occlusion stroke—Does age matter?

Objectives Endovascular treatment (EVT) is the gold standard treatment for emergent large vessel occlusion (LVO). The benefit of EVT for emergent LVO in elderly patients (>80 years old) is still debated as they have been under-represented in randomized controlled trials. Elderly patients with an emergent LVO are a growing population warranting further study. Materials & Methods We included 225 consecutive patients treated with EVT for LVO either in the anterior or posterior circulation. The clinical outcome was assessed using the National Institute of Health Stroke Scale (NIHSS). Long-term functional outcome was assessed using 90-day modified ranking scale (mRS). Results Neurological improvement: A five-year higher age predicted a 0.43 higher mean NIHSS score after EVT (p = .027). After adjusting for confounders (influencing variables), the association between age and post-interventional NIHSS was reduced and non-significant (p = .17). At discharge, a five-year higher age predicted a 0.74 higher mean NIHSS (p = .003). After adjusting for confounders this association was reduced and non-significant (p = .06). Long-term functional outcome: A five-year higher age predicted a 0.20 higher mRS at three months (p < .001). When adjusting for confounders this number was reduced to 0.16, yet still highly significant (p < .001). Conclusions Age seems to have a minor role in predicting neurological improvement after EVT but has an impact on long-term functional outcome. The decision to perform or withhold EVT should therefore not solely be based on age.publishedVersio

Pressor therapy in acute ischaemic stroke: an updated systematic review

Background Low blood pressure (BP) in acute ischaemic stroke (AIS) is associated with poor functional outcome, death, or severe disability. Increasing BP might benefit patients with post-stroke hypotension including those with potentially salvageable ischaemic penumbra. This updated systematic review considers the present evidence regarding the use of vasopressors in AIS. Methods We searched the Cochrane Database of Systematic Reviews, MEDLINE, EMBASE and trial databases using a structured search strategy. We examined reference lists of relevant publications for additional studies examining BP elevation in AIS. Results We included 27 studies involving 1886 patients. Nine studies assessed increasing BP during acute reperfusion therapy (intravenous thrombolysis, mechanical thrombectomy, intra-arterial thrombolysis or combined). Eighteen studies tested BP elevation alone. Phenylephrine was the most commonly used agent to increase BP (n = 16 studies), followed by norepinephrine (n = 6), epinephrine (n = 3) and dopamine (n = 2). Because of small patient numbers and study heterogeneity, a meta-analysis was not possible. Overall, BP elevation was feasible in patients with fluctuating or worsening neurological symptoms, large vessel occlusion with labile BP, sustained post-stroke hypotension and ineligible for intravenous thrombolysis or after acute reperfusion therapy. The effects on functional outcomes were largely unknown and close monitoring is advised if such intervention is undertaken. Conclusion Although theoretical arguments support increasing BP to improve cerebral blood flow and sustain the ischaemic penumbra in selected AIS patients, the data are limited and results largely inconclusive. Large, randomised controlled trials are needed to identify the optimal BP target, agent, duration of treatment and effects on clinical outcomes.acceptedVersio

Multiple simultaneous embolic cerebral infarctions 11 months after COVID-19

Background: The coronavirus disease (COVID-19) pandemic has led to an unprecedented worldwide burden of disease. However, little is known of the longer-term implications and consequences of COVID-19. One of these may be a COVID-19 associated coagulopathy that can present as a venous thromboembolism (VTE) and further, as multiple paradoxical cerebral emboli. Case presentation: A 51 year old man presented to the emergency department with multiple simultaneous embolic cerebral infarctions 11 months after mild COVID-19. In the subacute phase of the COVID-19 illness the patient developed increasing shortness of breath and was found to have an elevated D-dimer and multiple bilateral segmental pulmonary emboli. He was subsequently treated with 3 months of anticoagulation for a provoked VTE. The patient then presented 11 months after the initial COVID-19 diagnosis with multiple simultaneous cerebral infarctions where no traditional underlying stroke etiology was determined. A patent foramen ovale (PFO) and an elevated D-dimer were found suggesting a paradoxical thromboembolic event due to an underlying coagulopathy. Conclusions: This case report highlights the one of the potentially more serious complications of long-term COVID-19 where VTE due to a persistent coagulopathy is seen almost a year after the initial illness. Due to the highly prevalent nature of PFO in the general population, VTE due to COVID-19 associated coagulopathy could lead to ischemic stroke. This case report highlights the possibility for an underlying COVID-19 associated coagulopathy which may persist for many months and beyond the initial illness.publishedVersio

The golden hour of acute ischemic stroke

Abstract Background Acute Ischemic Stroke (AIS) treatment has been revolutionised in the last two decades with the increasing use of Intravenous Thrombolysis (IVT) and with the advent of Endovascular therapy (EVT). AIS treatment and outcome are time dependant and time saving measures are being implemented at every step of the treatment chain. These changes have resulted in lower treatment times in-hospital, but it is unclear if this translates into more patients being treated within 60 min of symptom onset – the Golden Hour. The clinical outcome of IVT therapy in this patient group was our secondary outcome. Methods From 2009 onwards, systematic changes were made to the AIS treatment chain leading to a dramatic decrease in Door-to-Needle (DTN) time. Analyses were performed on the number of these treatments year on year and their clinical outcomes within the Golden Hour at Stavanger University Hospital (SUS). Results Six-hundred and thirteen patients were included; seventy-three were treated within the Golden Hour. The percentage of total IVT treatments occurring in the Golden Hour rose from 2.2% in 2009 to 14.5% in 2015 (p = 0.006) with a high of 18.3% in 2012 (p < 0.001). All of these patients had a Median NIHSS of 0 at discharge, irrespective of age and pre-existing comorbidity. There was no incidence of any ICH and in-hospital mortality was only 2.7% in this group. Discussion The time from AIS symptom onset to treatment is filled with delays. Despite the inherence of some delays,significant efforts on the part of the pre- and in- hospital treatment chain have made IVT therapy within 60 min a possibility. The allocation and use of resources in the setting of rapid AIS treatment is warrantedand yields unprecedented results. Conclusions Our study shows that improved treatment routines led to an increase in the number of patients treated within the Golden Hour. Treatment in the Golden Hour leads to excellent outcomes in all patients, irrespective of age and pre-existing comorbidity

Evaluation of the Implementation of a Rapid Response Treatment Protocol for Patients with Acute Onset Stroke: Can We Increase the Number of Patients Treated and Shorten the Time Needed

Aims: This study aims to evaluate the implementation of a rapid response treatment protocol for patients presenting with acute onset ischemic stroke. Improvements of routines surrounding the admission and treatment of patients with intravenous thrombolysis (IVT), such as door-to-needle (DTN) times, and increasing the numbers of patients treated are discussed. Methods: We conducted a retrospective analysis of all patients (n = 320) treated with IVT for acute onset ischemic stroke at the Stavanger University Hospital, Norway, between 2003 and 2012. In 2009, a succession of changes to pre- and intra-hospital routines were made as well as an improvement in the education of primary health care physicians, nurses and paramedics involved in the treatment of acute onset stroke patients (rapid response treatment protocol). Analyses of DTN times, onset-to-needle times and the number of patients treated per year were carried out to ascertain the effect of the changes made. The primary aim was to analyze DTN times to look for any changes, and the secondary aim was to analyze changes in the number of patients treated per year. Results: In the years after the implementation of the rapid treatment protocol, we saw an improvement in the median DTN time with a decrease from 73 to 50 min in the first year (p = 0.03), a decrease of 45 min in the second year (p = 0.01) and a decrease of 31 min in the third year (p Conclusions: The implementation of the rapid treatment protocol for acute onset ischemic stroke patients led to a significant decrease in the DTN time at our center. These improvements also produced an increase in the number of patients treated per year. The extension of the therapeutic window from 3 to 4.5 h for the use of intravenous recombinant tissue plasminogen activator also played a role in the increased treatment numbers

Multiple simultaneous embolic cerebral infarctions 11 months after COVID-19

Background: The coronavirus disease (COVID-19) pandemic has led to an unprecedented worldwide burden of disease. However, little is known of the longer-term implications and consequences of COVID-19. One of these may be a COVID-19 associated coagulopathy that can present as a venous thromboembolism (VTE) and further, as multiple paradoxical cerebral emboli. Case presentation: A 51 year old man presented to the emergency department with multiple simultaneous embolic cerebral infarctions 11 months after mild COVID-19. In the subacute phase of the COVID-19 illness the patient developed increasing shortness of breath and was found to have an elevated D-dimer and multiple bilateral segmental pulmonary emboli. He was subsequently treated with 3 months of anticoagulation for a provoked VTE. The patient then presented 11 months after the initial COVID-19 diagnosis with multiple simultaneous cerebral infarctions where no traditional underlying stroke etiology was determined. A patent foramen ovale (PFO) and an elevated D-dimer were found suggesting a paradoxical thromboembolic event due to an underlying coagulopathy. Conclusions: This case report highlights the one of the potentially more serious complications of long-term COVID-19 where VTE due to a persistent coagulopathy is seen almost a year after the initial illness. Due to the highly prevalent nature of PFO in the general population, VTE due to COVID-19 associated coagulopathy could lead to ischemic stroke. This case report highlights the possibility for an underlying COVID-19 associated coagulopathy which may persist for many months and beyond the initial illness

Time-Based Decision Making for Reperfusion in Acute Ischemic Stroke

Decision making in the extended time windows for acute ischemic stroke can be a complex and time-consuming process. The process of making the clinical decision to treat has been compounded by the availability of different imaging modalities. In the setting of acute ischemic stroke, time is of the essence and chances of a good outcome diminish by each passing minute. Navigating the plethora of advanced imaging modalities means that treatment in some cases can be inefficaciously delayed. Time delays and individually based non-programmed decision making can prove challenging for clinicians. Visual aids can assist such decision making aimed at simplifying the use of advanced imaging. Flow charts are one such visual tool that can expedite treatment in this setting. A systematic review of existing literature around imaging modalities based on site of occlusion and time from onset can be used to aid decision making; a more program-based thought process. The use of an acute reperfusion flow chart helping navigate the myriad of imaging modalities can aid the effective treatment of patients.publishedVersio

Thrombectomy in large vessel occlusion stroke—Does age matter?

Objectives Endovascular treatment (EVT) is the gold standard treatment for emergent large vessel occlusion (LVO). The benefit of EVT for emergent LVO in elderly patients (>80 years old) is still debated as they have been under-represented in randomized controlled trials. Elderly patients with an emergent LVO are a growing population warranting further study. Materials & Methods We included 225 consecutive patients treated with EVT for LVO either in the anterior or posterior circulation. The clinical outcome was assessed using the National Institute of Health Stroke Scale (NIHSS). Long-term functional outcome was assessed using 90-day modified ranking scale (mRS). Results Neurological improvement: A five-year higher age predicted a 0.43 higher mean NIHSS score after EVT (p = .027). After adjusting for confounders (influencing variables), the association between age and post-interventional NIHSS was reduced and non-significant (p = .17). At discharge, a five-year higher age predicted a 0.74 higher mean NIHSS (p = .003). After adjusting for confounders this association was reduced and non-significant (p = .06). Long-term functional outcome: A five-year higher age predicted a 0.20 higher mRS at three months (p < .001). When adjusting for confounders this number was reduced to 0.16, yet still highly significant (p < .001). Conclusions Age seems to have a minor role in predicting neurological improvement after EVT but has an impact on long-term functional outcome. The decision to perform or withhold EVT should therefore not solely be based on age