Supplementary Material for: Magnetic Resonance Imaging-Based versus Computed Tomography-Based Thrombolysis in Acute Ischemic Stroke: Comparison of Safety and Efficacy within a Cohort Study

<b><i>Background:</i></b> In acute ischemic stroke, brain imaging is mandatory in the decision whether to perform intravenous thrombolysis with recombinant tissue plasminogen activator. The most widespread used imaging modality to exclude intracranial hemorrhage is plain computed tomography (CT). However, there is an ongoing debate whether the information provided by magnetic resonance imaging (MRI) could improve the selection of patients for thrombolysis. We investigated whether the choice of imaging modality (MRI vs. CT) affects therapy safety and the patients' outcome. <b><i>Methods:</i></b> Analyses are based on data from a prospective, single-center observational study that included all patients with acute ischemic stroke who received intravenous thrombolysis within 4.5 h. Stroke severity was assessed by the National Institutes of Health Stroke Scale. Safety was assessed by rates of symptomatic intracranial hemorrhage (SICH), brain edema with mass effect and 7-day mortality. Outcome was assessed at 3 months as mortality and proportion of independent patients (modified Rankin Scale score between 0 and 2). <b><i>Results:</i></b> We analyzed 345 patients of whom 141 received multimodal MRI and 204 received plain CT prior to treatment. Groups did not differ significantly in terms of age, neurological deficit, rate of elevated glucose level or rate of very high blood pressure. However, patients with CT-based thrombolysis had significantly higher rates of cardiac comorbidities (coronary artery disease, heart failure). In the MRI group, we observed a lower rate of 7-day mortality (1 vs. 10%; p = 0.001), a lower rate of SICH (1 vs. 6%; p = 0.010) and a nonsignificantly lower rate of brain edema with mass effect (2 vs. 6%; n.s.). In multivariable analysis, 7-day mortality was independently associated with MRI-based thrombolysis, even if cardiac comorbidities were taken into account. For mortality at 3 months, there was a nonsignificant difference in favor of the MRI group (16 vs. 23%; n.s.). In multivariable analyses, mortality at 3 months was independently associated with older age, higher stroke severity, brain edema with mass effect, SICH, pneumonia and coronary artery disease. Neither mortality nor independent outcome was influenced by initial imaging modality. <b><i>Conclusions:</i></b> Thrombolysis based on multimodal MRI is associated with reduced rates of SICH and early death. Our results suggest that these complications affect survival principally in the acute phase after thrombolysis. However, nonneurological and especially cardiac comorbidities also influence survival after stroke and are underrepresented in stroke patients undergoing MRI. Selection bias has to be considered

Supplementary Material for: MRI Follow-Up after 24 h Is an Accurate Surrogate Parameter for Treatment Success after Thrombolysis

Medicin

Supplementary Material for: Age Dependency of Successful Recanalization in Anterior Circulation Stroke: The ENDOSTROKE Study

<b><i>Background:</i></b> Clinical outcome after endovascular stroke therapy (EVT) for proximal anterior circulation stroke is often disappointing despite high recanalization rates. The ENDOSTROKE study aims to determine predictors of clinical outcome in patients undergoing EVT. Here we focus on the impact of age and recanalization on proximal middle cerebral artery (M1-MCA) or carotid T occlusion. <b><i>Methods:</i></b> ENDOSTROKE is an investigator-initiated, industrially independent multicenter registry launched in January, 2011, for consecutive patients undergoing EVT for large-vessel stroke. This analysis focuses on patients treated in 11 academic and nonacademic stroke centers with angiographically proven M1-MCA (n = 259) or carotid T occlusion (n = 103). Recanalization was defined as Thrombolysis in Myocardial Infarction (TIMI) score 2 or 3, and in patients with available Thrombolysis in Cerebral Ischemia (TICI) data (n = 309) as TICI scores 2b-3. Good outcome was defined as modified Rankin Scale (mRS) score of 0-2 assessed after 3 months or later. <b><i>Results:</i></b> The median age was 68 years (25th and 75th percentiles: 56, 76 years), and the median National Institutes of Health Stroke Scale (NIHSS) score at admission was 16 (13, 19); 41% of the patients had a favorable (mRS scores 0-2), and 59% had an unfavorable (mRS scores 3-6) outcome; 83% reached TIMI 2-3 flow. Independent predictors of good outcome were younger age, lower initial NIHSS scores, TIMI 2/3 recanalization and lower serum glucose levels. Outcome was highly dependent on patients' age: 60% of the patients within the lowest age quartile (range: 18-56 years) experienced good clinical outcome, decreasing stepwise over 47% (57-68 years) and 37% (69-76 years) to 17% in the highest age quartile (77-94 years). The proportion of patients with poor clinical outcome despite TIMI 2/3 recanalization (‘futile recanalization') increased dramatically from only 29% in the lowest age quartile over 34% and 40% (2nd and 3rd age quartiles) up to 53% in the highest age quartile. Results were similar in patients with available TICI scores, with ‘futile recanalization' rates increasing from 24% to 46% (lowest to highest age quartile). <b><i>Conclusions:</i></b> This study emphasizes the dramatic impact of patients' age on outcome in EVT for M1-MCA or carotid T occlusion, even in the presence of recanalization. Reasons for this age-related decrease in clinically successful recanalization rates urgently need clarification and may comprise patient-related factors (age-related increase in cardioembolic strokes, collateral status, comorbidities) as well as periprocedural issues (tortuous vessel anatomy in the elderly, age-dependent negative impact of general anesthesia in EVT)