A Score for Risk of Thrombolysis-Associated Hemorrhage Including Pretreatment with Statins

Background: Symptomatic intracranial hemorrhage (sICH) after intravenous thrombolysis with recombinant tissue-plasminogen activator (rt-PA) for acute ischemic stroke is associated with a poor functional outcome. We aimed to develop a score assessing risk of sICH including novel putative predictors—namely, pretreatment with statins and severe renal impairment. Methods: We analyzed our local cohort (Berlin) of patients receiving rt-PA for acute ischemic stroke between 2006 and 2016. Outcome was sICH according to ECASS-III criteria. A multiple regression model identified variables associated with sICH and receiver operating characteristics were calculated for the best discriminatory model for sICH. The model was validated in an independent thrombolysis cohort (Basel). Results: sICH occurred in 53 (4.0%) of 1,336 patients in the derivation cohort. Age, baseline National Institutes of Health Stroke Scale, systolic blood pressure on admission, blood glucose on admission, and prior medication with medium- or high-dose statins were associated with sICH and included into the risk of intracranial hemorrhage score. The validation cohort included 983 patients of whom 33 (3.4%) had a sICH. c-Statistics for sICH was 0.72 (95% CI 0.66–0.79) in the derivation cohort and 0.69 (95% CI 0.60–0.77) in the independent validation cohort. Inclusion of severe renal impairment did not improve the score. Conclusion: We developed a simple score with fair discriminating capability to predict rt-PA- related sICH by adding prior statin use to known prognostic factors of sICH. This score may help clinicians to identify patients with higher risk of sICH requiring intensive monitoring

Independent external validation of a stroke recurrence score in patients with embolic stroke of undetermined source

Abstract Background Embolic stroke of undetermined source (ESUS) accounts for a substantial proportion of ischaemic strokes. A stroke recurrence score has been shown to predict the risk of recurrent stroke in patients with ESUS based on a combination of clinical and imaging features. This study aimed to externally validate the performance of the ESUS recurrence score using data from a randomized controlled trial. Methods The validation dataset consisted of eligible stroke patients with available magnetic resonance imaging (MRI) data enrolled in the PreDAFIS sub-study of the MonDAFIS study. The score was calculated using three variables: age (1 point per decade after 35 years), presence of white matter hyperintensities (2 points), and multiterritorial ischaemic stroke (3 points). Patients were assigned to risk groups as described in the original publication. The model was evaluated using standard discrimination and calibration methods. Results Of the 1054 patients, 241 (22.9%) were classified as ESUS. Owing to insufficient MRI quality, three patients were excluded, leaving 238 patients (median age 65.5 years [IQR 20.75], 39% female) for analysis. Of these, 30 (13%) patients experienced recurrent ischaemic stroke or transient ischemic attack (TIA) during a follow-up period of 383 patient-years, corresponding to an incidence rate of 7.8 per 100 patient-years (95% CI 5.3–11.2). Patients with an ESUS recurrence score value of ≥ 7 had a 2.46 (hazard ratio (HR), 95% CI 1.02–5.93) times higher risk of stroke recurrence than patients with a score of 0–4. The cumulative probability of stroke recurrence in the low-(0–4), intermediate-(5–6), and high-risk group (≥ 7) was 9%, 13%, and 23%, respectively (log-rank test, χ2 = 4.2, p = 0.1). Conclusions This external validation of a published scoring system supports a threshold of ≥ 7 for identifying ESUS patients at high-risk of stroke recurrence. However, further adjustments may be required to improve the model’s performance in independent cohorts. The use of risk scores may be helpful in guiding extended diagnostics and further trials on secondary prevention in patients with ESUS. Trial registration: Clinical Trials, NCT02204267. Registered 30 July 2014, https://clinicaltrials.gov/ct2/show/NCT02204267

Tandem occlusion impairs outcome in intravenous thrombolyzed stroke patients

Es wird kontrovers diskutiert, ob eine Tandem-Okklusion hirnversorgender Arterien im vorderen Stromgebiet (zeitgleiche Okklusion der extrakraniellen A. carotis interna und der ipsilateralen A. cerebri media) das klinische und vaskuläre Outcome intravenös (IV) mit Alteplase behandelter Schlaganfallpatienten beeinflusst. Methoden Aus einer fortlaufend geführten Datenbank mit akut behandelten Schlaganfallpatienten wurden alle Patienten identifiziert, die in einer Magnetresonanz- oder Computertomogramm- Angiographie (MR-A, CT-A) vor IV Thrombolyse eine A. cererbi media-Okklusion (ACM-O) mit oder ohne ipsilaterale extrakranielle A. carotis interna-Okklusion (eACI-O) (Tandem-Okklusion) aufgewiesen hatten. Die Symptome bestanden bei allen Patienten nicht länger als 4,5 Stunden. Patienten mit Tandem-Okklusion wurden mit Patienten welche eine singuläre ACM-O aufwiesen hinsichtlich des guten klinischen Outcomes 3 Monate nach Ereignis verglichen. Dazu diente die modifizierte Rankin-Skala (mRS). Als gutes klinisches Outcome wurde ein mRS ≤ 2 definiert. Zusätzlich wurden die Patienten hinsichtlich der Rate an symptomatischer intrazerebraler Blutung (sICB) und dem Auftreten einer Pneumonie verglichen. Bei einem Teil dieser Studienpopulation wurde innerhalb von 24h eine erneute MR-A oder CT-A durchgeführt. In dieser Subpopulation wurden Patienten mit Tandem-Okklusion mit Patienten welche eine singuläre ACM-O aufwiesen hinsichtlich der erfolgreichen Rekanalisationsrate der ACM verglichen. Hierfür diente die Thrombolysis in Cerebral Infaction Skala (TICI). Als erfolgreiche Rekanalisation wurde TICI 2b-3 festegelegt. Ergebnisse Von insgesamt 752 Patienten erhielten 375 eine Angiographie vor Einleitung der Akutbehandlung. Von 375 Patienten hatten 110 Patienten eine akute singuläre ACM-O oder eine akute Tandem-Okklusion. Von 110 Patienten hatten 83% (91) eine singuläre ACM-O und 17 % (19) eine Tandem-Okklusion. Die Patienten mit einer Tandem-Okklusion waren initial klinisch schwerer betroffen (National Institutes of Health Stroke Scale (NIHSS); Median [IQR] 18 [13-22] vs. 14 [7-19], p=0.03), hatten seltener ein gutes klinisches Outcome (mRS ≤ 2: 11% vs. 48%; p 0,02) und häufiger eine Pneumonie nach Schlaganfall (53% vs. 17%, p<0,01) als Patienten mit einer singulären ACM-O. Die Rate an sICB war in den Gruppen nicht signifikant unterschiedlich. In der Subpopulation der Patienten mit Gefäßdarstellung nach IV Thrombolyse hatten 20% (13) eine Tandem-Okklusion. Die Patienten mit einer Tandem-Okklusion hatten seltener eine erfolgreiche Rekanalisation der ACM (TICI2b-3: 23% vs. 59%; p=0.03). In einer multivariaten Regressionsanalyse für erfolgreiche Rekanalisation der ACM (adjustiert für Alter, Schlaganfallschweregrad, Zeit zwischen Symptombeginn und Therapiebeginn und Lokalisation des intrakraniellen Gefäßverschlusses) war eine Tandem-Okklusion mit einer fehlenden erfolgreichen Rekanalisation der ACM assoziiert; TICI2b-3 (OR [95% CI]= 4,24 [1,04-17,31]; p=0,04). Die eICA-O rekanalisierte zu 85% (11). Schlussfolgerung Eine Tandem-Okklusion beeinflusst das klinische und vaskuläre Outcome bei IV thrombolysierten Schlaganfallpatienten negativ.Background and Purpose We aimed to describe the influence of an additional extracranial internal carotid artery occlusion (eICA-O) (tandem occlusion) on recanalization and clinical outcome in acute stroke patients with occlusion of the middle cerebral artery (MCA) undergoing intravenous (IV) thrombolysis. Methods Acute stroke patients with proven MCA occlusion (MCA-O) with or without eICA-O on CT-angiography (CT-A) or MR-angiography (MR-A) with a symptom onset less then 4.5hrs were identified in our ongoing thrombolysis register. Clinical outcome was assessed using the modified Rankin Scale (mRS) three months after stroke (independent outcome = mRS ≤ 2). Furthermore the occurrence of post-stroke pneumonia and rate of symptomatic intracrerbral hemorrhage (sICH) were recorded as additional clinical outcome variables. Vascular outcome was measured in a subgroup of patients with conducted follow- up angiography within 24hrs on CT-A or MR-A. Successful recanalization of MCA was defined as “Thrombolysis In Cerebral Infarction” (TICI) classification 2b-3. Results Out of 752 patients 375 patients had a CT-A or MR-A before administration IV rt-PA. Of these 375 patients 110 had a single MCA-O or a tandem-occlusion. Single MCA-O was seen in 85% (91) and Tandem- occlusion in 17% (19) of these 110 patients. Patients with tandem-occlusion were more severely effected (National Institutes of Health Stroke Scale (NIHSS); median [IQR] 18 [13-22] vs. 14 [7-19], p=0.03), had less often independent outcome (mRS ≤ 2) (11% vs. 48%; p=0.02) and had more often post-stroke pneumonia (53% vs. 17%, p<0.01) than patients with MCA-O only. The rate of sICH did not differ significantly in both groups. Furthermore data of a subgroup with patients who had vascular imaging within 24 hours after IV thrombolysis was analyzed respective to the vascular outcome. Patients with eICA occlusion had lower rate of successful recanalization of occluded MCA (TICI 2b-3: 23% vs. 59%; p=0.03). An eICA occlusion was independently associated (OR [95% CI]=4,24 [1,04-17,31]; p=0,04) with absent recanalization adjusted for age, onset to treatment time, site of intracranial vessel occlusion and NIHSS on admission. eICA-O recanalized in eleven Patients (85%). Summary Presence of tandem- occlusion affects clinical and vascular outcome in IV thrombolyzed stroke patients negatively

From Bad to Worse: Intravenous Thrombolysis in Tandem Occlusion

We report a stroke patient with tandem occlusion of both the distal middle cerebral artery (MCA) and the ipsilateral internal carotid artery (ICA) who clinically deteriorated after intravenous thrombolysis in spite of recanalization of the ICA because of new proximal MCA (main-stem) occlusion. We discuss this unfortunate course (clinical deterioration in spite of partial recanalization) in the light of the characteristics of human brain vasculature and argue in favour of a more aggressive reperfusion strategy in this special settin

Preoperative therapeutic plasmapheresis in thyrotoxic patients who did not effectively treated with antithyroid drugs, iodine and corticosteroid

Introduction: Preoperative treatment options in thyrotoxic patients are antithyroid drugs, potassium iodide, beta blockers and corticosteroids. Sometimes these treatment regimens have not been so successful for the patients to make them ready for the operation. So we thought that plasmapheresis (PP) could be an alternative to these treatments. Methods: Two thyrotoxic patients with Graves' disease and one patient with toxic multinodular goiter were included in the study. All patients were candidates to surgical operation due to the contraindication of other medical treatment choices. On admission, all patients had severe uncontrolled hyperthyroidism. In order to prepare our patients to operation, all the patients were given beta blockers and inorganic potassium iodide and corticosteroid at first but disease control could not be achieved in terms of thyrotoxicosis. So PP was performed at an average of 3 to 5 sessions. Results: After PP, all patients' thyroid hormone concentrations were significantly reduced. One patient had an anaphylactic reaction during 3th session of PP. Total thyroidectomy was performed to all patients without any complications. Conclusions: We concluded that PP could be used as an alternative therapeutic option in the preoperative management of severe thyrotoxic patients. © 2010 Düzce Medical Journal

Non‐invasive telemedical care in heart failure patients and stroke: post hoc analysis of TIM‐HF and TIM‐HF2 trials

Aims: Patients with chronic heart failure (CHF) have an increased risk of ischaemic stroke. We aimed to identify the incidence rate and factors associated with ischaemic stroke or transient ischaemic attack (TIA) in CHF patients as well as the impact of non-invasive telemedical care (NITC) on acute stroke/TIA. Methods and results: We retrospectively analysed baseline characteristics of 2248 CHF patients enrolled to the prospective multicentre Telemedical Interventional Monitoring in Heart Failure study (TIM-HF) and Telemedical Interventional Management in Heart Failure II study (TIM-HF2), randomizing New York Heart Association (NYHA) II/III patients 1:1 to NITC or standard of care. Hospitalizations due to acute ischaemic stroke or TIA during a follow-up of 12 months were analysed. Old age, hyperlipidaemia, lower body mass index, and peripheral arterial occlusive disease (PAOD) were independently associated with present cerebrovascular disease on enrolment. The stroke/TIA rate was 1.5 per 100 patients-years within 12 months after randomization (n = 32, 1.4%). Rate of stroke/TIA within 12 months was in the intervention group similar compared with the control group (50.0% vs. 49.8%; P = 0.98) despite that the rate of newly detected atrial fibrillation (AF) was higher in the intervention group (14.1% vs. 1.6%; P < 0.001). A history of PAOD (OR 2.7, 95% CI 1.2–6.2; P = 0.02) and the highest tertile (OR 3.0, 95% CI 1.1–8.3) of N-terminal pro-brain natriuretic peptide (NT-proBNP) on enrolment were associated with stroke/TIA during follow-up. In patients who suffered acute stroke or TIA during follow-up, echocardiography was part of the diagnostic workup in only 56% after hospital admission. Conclusions: Annual rate of ischaemic stroke/TIA in NYHA II/III patients is low but higher in those with elevated NT-proBNP levels and history of PAOD at baseline. NITC showed no impact on the stroke rate during 1 year follow-up despite a significantly higher rate of newly detected AF. Irrespective of known CHF, echocardiography was often missing during in-hospital diagnostic workup after acute stroke/TIA