Thrombolysis in very elderly people: controlled comparison of SITS international stroke thrombolysis registry and virtual international stroke trials archive

<p>Objective To assess effect of age on response to alteplase in acute ischaemic stroke.</p> <p>Design Adjusted controlled comparison of outcomes between non-randomised patients who did or did not undergo thrombolysis. Analysis used Cochran-Mantel-Haenszel test and proportional odds logistic regression analysis.</p> <p>Setting Collaboration between International Stroke Thrombolysis Registry (SITS-ISTR) and Virtual International Stroke Trials Archive (VISTA).</p> <p>Participants 23 334 patients from SITS-ISTR (December 2002 to November 2009) who underwent thrombolysis and 6166 from VISTA neuroprotection trials (1998-2007) who did not undergo thrombolysis (as controls). Of the 29 500 patients (3472 aged >80 (“elderly,” mean 84.6), data on 272 patients were missing for baseline National Institutes of Health stroke severity score, leaving 29 228 patients for analysis adjusted for age and baseline severity.</p> <p>Main outcome measures Functional outcomes at 90 days measured by score on modified Rankin scale.</p> <p>Results Median severity at baseline was the same for patients who underwent thrombolysis and controls (median baseline stroke scale score: 12 for each group, P=0.14; n=29 228). The distribution of scores on the modified Rankin scale was better among all thrombolysis patients than controls (odds ratio 1.6, 95% confidence interval 1.5 to 1.7; Cochran-Mantel-Haenszel P<0.001). The association occurred independently among patients aged ≤80 (1.6, 1.5 to 1.7; P<0.001; n=25 789) and in those aged >80 (1.4, 1.3 to 1.6; P0.001; n=3439). Odds ratios were consistent across all 10 year age ranges above 30, and benefit was significant from age 41 to 90; dichotomised outcomes (score on modified Rankin scale 0-1 v 2-6; 0-2 v 3-6; and 6 (death) v rest) were consistent with the results of the ordinal analysis.</p> <p>Conclusions Outcome in patients with acute ischaemic stroke is significantly better in those who undergo thrombolysis compared with those who do not. Increasing age is associated with poorer outcome but the association between thrombolysis treatment and improved outcome is maintained in very elderly people. Age alone should not be a barrier to treatment.</p&gt

Endovascular Treatment for Acute Isolated Internal Carotid Artery Occlusion : A Propensity Score Matched Multicenter Study.

The benefit of endovascular treatment (EVT) in patients with acute symptomatic isolated occlusion of the internal carotid artery (ICA) without involvement of the middle and anterior cerebral arteries is unclear. We aimed to compare clinical and safety outcomes of best medical treatment (BMT) versus EVT + BMT in patients with stroke due to isolated ICA occlusion. We conducted a retrospective multicenter study involving patients with isolated ICA occlusion between January 2016 and December 2020. We stratified patients by BMT versus EVT and matched the groups using propensity score matching (PSM). We assessed the effect of treatment strategy on favorable outcome (modified Rankin scale ≤ 2) 90 days after treatment and compared reduction in NIHSS score at discharge, rates of symptomatic intracranial hemorrhage (sICH) and 3‑month mortality. In total, we included 149 patients with isolated ICA occlusion. To address imbalances, we matched 45 patients from each group using PSM. The rate of favorable outcomes at 90 days was 56% for EVT and 38% for BMT (odds ratio, OR 1.89, 95% confidence interval, CI 0.84-4.24; p = 0.12). Patients treated with EVT showed a median reduction in NIHSS score at discharge of 6 points compared to 1 point for BMT patients (p = 0.02). Rates of symptomatic intracranial hemorrhage (7% vs. 4%; p = 0.66) and 3‑month mortality (11% vs. 13%; p = 0.74) did not differ between treatment groups. Periprocedural complications of EVT with early neurological deterioration occurred in 7% of cases. Although the benefit on functional outcome did not reach statistical significance, the results for NIHSS score improvement, and safety support the use of EVT in patients with stroke due to isolated ICA occlusion

Loss of Penumbra by Impaired Oxygen Supply Decreasing Hemoglobin Levels Predict Infarct Growth after Acute Ischemic Stroke

Background: The association of mortality and poor outcome with reduced levels of hemoglobin (Hb) and hematocrit (Hct) in patients admitted for ischemic stroke was recently demonstrated. The mechanisms behind this have remained unclear. Aims: Here, we aimed to investigate a putative association between low Hb and Hct levels and infarct growth. Methods: All consecutive patients who received intravenous thrombolysis based on multimodal magnetic resonance imaging during the years 1998–2009 were screened. Laboratory data as well as admission magnetic resonance images and follow-up computed tomography scans of 257 patients were assessed. Overall, data of 100 patients were of sufficient quality and further analyzed. Results: Decrease in Hb and Hct as well as perfusion-weighted imaging volume, mismatch volume, and final infarct size on follow-up computed tomography were associated with infarct growth. A linear regression model revealed Hb decrease (β = 0.23, p = 0.02) to be a predictor of infarct growth, independent of mismatch volume (β = 0.27, p = 0.004) and minimum sodium (β = -0.21, p = 0.03), and adjusted to the non-predicting variables age, National Institute of Health Stroke Scale score, maximum leucocytes and C-reactive protein, blood glucose, and Hct decrease. Conclusion: Hb levels that decrease after admission independently predict infarct growth in thrombolyzed stroke patients. The clinical implications of this relationship remain to be investigated

Supplementary Material for: Repeated Intravenous Treatment with Recombinant Tissue-Type Plasminogen Activator in Patients with Acute Ischemic Stroke

<b><i>Objective:</i></b> Increased use of systemic thrombolysis, demographic changes, and higher chances of surviving first-ever strokes all lead to an increasing number of patients with recurrent stroke. However, data on repeated thrombolysis are limited. Here, we report on the safety and clinical effects of repeated intravenous recombinant tissue-type plasminogen activator (rt-PA) treatment in a large consecutive cohort of stroke patients. <b><i>Methods:</i></b> We identified all stroke patients who received repeated thrombolysis. We determined safety and 3-month clinical outcome after the first and second thrombolysis. All patients received follow-up brain imaging. Good clinical outcome was defined as a modified Rankin Scale of 0-2 or recovery to the prestroke status. <b><i>Results:</i></b> In total, 24 patients were included (i.e. 1.5% of all stroke patients treated with rt-PA at our center who survived the first treatment; male 45.8%; median age at first event: 74.5 years). No allergic or anaphylactic reactions were recorded after the first time of treatment, but oral angioedema developed once during the second treatment. No symptomatic intracerebral hemorrhage was observed. Clinical outcome was good in 75.0% after the first, but in only 41.7% after the second treatment (p = 0.021). <b><i>Conclusions:</i></b> Repeated thrombolysis was not associated with a higher rate of complications. However, the clinical outcome appears to be less satisfactory than after the first treatment

Hyperdense Artery Sign in Patients With Acute Ischemic Stroke–Automated Detection With Artificial Intelligence-Driven Software

Background: Hyperdense artery sign (HAS) on non-contrast CT (NCCT) can indicate a large vessel occlusion (LVO) in patients with acute ischemic stroke. HAS detection belongs to routine reporting in patients with acute stroke and can help to identify patients in whom LVO is not initially suspected. We sought to evaluate automated HAS detection by commercial software and compared its performance to that of trained physicians against a reference standard. Methods: Non-contrast CT scans from 154 patients with and without LVO proven by CT angiography (CTA) were independently rated for HAS by two blinded neuroradiologists and an AI-driven algorithm (Brainomix®). Sensitivity and specificity were analyzed for the clinicians and the software. As a secondary analysis, the clot length was automatically calculated by the software and compared with the length manually outlined on CTA images as the reference standard. Results: Among 154 patients, 84 (54.5%) had CTA-proven LVO. HAS on the correct side was detected with a sensitivity and specificity of 0.77 (CI:0.66–0.85) and 0.87 (0.77–0.94), 0.8 (0.69–0.88) and 0.97 (0.89–0.99), and 0.93 (0.84–0.97) and 0.71 (0.59–0.81) by the software and readers 1 and 2, respectively. The automated estimation of the thrombus length was in moderate agreement with the CTA-based reference standard [intraclass correlation coefficient (ICC) 0.73]. Conclusion: Automated detection of HAS and estimation of thrombus length on NCCT by the tested software is feasible with a sensitivity and specificity comparable to that of trained neuroradiologists. Copyright © 2022 Weyland, Papanagiotou, Schmitt, Joly, Bellot, Mokli, Ringleb, Kastrup, Möhlenbruch, Bendszus, Nagel and Herweh