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Muacevic A, Adler JR, Alhazzani A, Alahmari F, Wassel Y, Elsayed E, Abdrabou A, Bassiouny Mohamed AA. Correlation Between Pre-treatment Collateral Status and Short-Term Functional Outcome in Patients With Mild to Moderate Stroke After Reperfusion Therapy in a Local Primary Stroke Center in the Southwestern Part of Saudi Arabia. Cureus 2023; 15:e33997. [PMID: 36811050 PMCID: PMC9939011 DOI: 10.7759/cureus.33997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/20/2023] [Indexed: 01/22/2023] Open
Abstract
Background Stroke is a substantial cause of disability and mortality worldwide and is characterized by the sudden onset of acute neurological deficit. During acute ischemia, cerebral collateral circulations are crucial in preserving blood supply to the ischemic region. Recombinant tissue plasminogen activator (r-tPA) and endovascular mechanical thrombectomy (MT) are the primary standards of care for acute recanalization therapy. Methodology From August 2019 through December 2021, we enrolled patients treated in our local primary stroke center with anterior circulation acute ischemic stroke (AIS) treated with intravenous thrombolysis (IVT) with or without MT. Only patients diagnosed with mild to moderate anterior ischemic stroke, as measured by the National Institutes of Health Stroke Scale (NIHSS), were included in the study. The candidate patients underwent non-contrast CT scanning (NCCT) and CT angiography (CTA) at admission. The modified Rankin scale (mRS) was used to assess the functional outcome of the stroke. The modified Tan scale, graded on a scale of 0-3, was used to determine the collateral status. Results This study comprised a total of 38 patients who had anterior circulation ischemic strokes. The mean age was 34. 8±13. All patients received IVT; eight patients (21.1%) underwent MT following r-tPA. In 26.3% of cases, hemorrhagic transformation (HT), both symptomatic and asymptomatic, was evident. Thirty-three participants (86.8%) had a moderate stroke, whereas five participants (13.2%) had a minor stroke. With a P-value of 0.003, a poor collateral status on the modified Tan score is substantially associated with a short, poor functional outcome. Conclusion In our study, patients with mild to moderate AIS with good collateral scores at admission had better short-term outcomes. Patients with poor collaterals tend to present with a disturbed level of consciousness more than patients with good collaterals.
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Yaghi S, Mistry E, de Havenon A, Leon Guerrero CR, Nouh A, Liberman AL, Giles J, Liu A, Nagy M, Kaushal A, Azher I, Mac Grory B, Fakhri H, Brown Espaillat K, Asad SD, Pasupuleti H, Martin H, Tan J, Veerasamy M, Esenwa C, Cheng N, Moncrieffe K, Moeini-Naghani I, Siddu M, Scher E, Trivedi T, Wu T, Khan M, Keyrouz S, Furie K, Henninger N. Effect of Alteplase Use on Outcomes in Patients With Atrial Fibrillation: Analysis of the Initiation of Anticoagulation After Cardioembolic Stroke Study. J Am Heart Assoc 2021; 10:e020945. [PMID: 34323120 PMCID: PMC8475683 DOI: 10.1161/jaha.121.020945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Intravenous alteplase improves outcome after acute ischemic stroke without a benefit in 90‐day mortality. There are limited data on whether alteplase is associated with reduced mortality in patients with atrial fibrillation (AF)‐related ischemic stroke whose mortality rate is relatively high. We sought to determine the association of alteplase with hemorrhagic transformation and mortality in patients with AF. Methods and Results We retrospectively analyzed consecutive patients with acute ischemic stroke between 2015 and 2018 diagnosed with AF included in the IAC (Initiation of Anticoagulation After Cardioembolic Stroke) study, which pooled data from stroke registries at 8 comprehensive stroke centers across the United States. For our primary analysis, we included patients who did not undergo mechanical thrombectomy (MT), and secondary analyses included patients who underwent MT. We used binary logistic regression to determine whether alteplase use was associated with risk of hemorrhagic transformation and 90‐day mortality. There were 1889 patients (90.6%) who had 90‐day follow‐up data available for analyses and were included; 1367 patients (72.4%) did not receive MT, and 522 patients (27.6%) received MT. In our primary analyses we found that alteplase use was independently associated with an increased risk for hemorrhagic transformation (odds ratio [OR], 2.23; 95% CI, 1.57–3.17) but reduced risk of 90‐day mortality (OR, 0.58; 95% CI, 0.39–0.87). Among patients undergoing MT, alteplase use was not associated with a significant reduction in 90‐day mortality (OR, 0.68; 95% CI, 0.45–1.04). Conclusions Alteplase reduced 90‐day mortality of patients with acute ischemic stroke with AF not undergoing MT. Further study is required to assess the efficacy of alteplase in patients with AF undergoing MT.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology Brown University Providence RI
| | - Eva Mistry
- Department of Neurology Vanderbilt University Nashville TN
| | - Adam de Havenon
- Department of Neurology University of Utah Salt Lake City UT
| | | | - Amre Nouh
- Department of Neurology Hartford Hospital Hartford CT
| | - Ava L Liberman
- Department of Neurology Montefiore Medical Center New York NY
| | - James Giles
- Department of Neurology Washington University Saint Louis MO
| | - Angela Liu
- Department of Neurology Washington University Saint Louis MO
| | - Muhammad Nagy
- Department of Neurology Hackensack Medical Center Hackensack NJ
| | | | - Idrees Azher
- Department of Neurology Brown University Providence RI
| | | | - Hiba Fakhri
- Department of Neurology Vanderbilt University Nashville TN
| | | | | | | | - Heather Martin
- Department of Neurology Spectrum Health, Grand Rapids MI
| | - Jose Tan
- Department of Neurology Spectrum Health, Grand Rapids MI
| | | | - Charles Esenwa
- Department of Neurology Montefiore Medical Center New York NY
| | - Natalie Cheng
- Department of Neurology Montefiore Medical Center New York NY
| | | | | | - Mithilesh Siddu
- Department of Neurology George Washington University Washington DC
| | - Erica Scher
- Department of Neurology New York University New York NY
| | | | - Teddy Wu
- Department of Neurology Christchurch Hospital Christchurch New Zealand
| | - Muhib Khan
- Department of Neurology Spectrum Health, Grand Rapids MI
| | - Salah Keyrouz
- Department of Neurology Washington University Saint Louis MO
| | - Karen Furie
- Department of Neurology Brown University Providence RI
| | - Nils Henninger
- Department of Neurology University of Massachusetts Worcester MA.,Department of Psychiatry University of Massachusetts Worcester MA
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Yuan T, Ren G, Hu X, Geng L, Li X, Xia S, Quan G. Added assessment of middle cerebral artery and atrial fibrillation to FLAIR vascular hyperintensity-DWI mismatch would improve the outcome prediction of acute infarction in patients with acute internal carotid artery occlusion. Neurol Sci 2019; 40:2617-2624. [PMID: 31392639 DOI: 10.1007/s10072-019-04029-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 07/22/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND AIMS Whether fluid-attenuated inversion recovery (FLAIR) vascular hyperintensities (FVH)-DWI mismatch could predict the outcome or not remains in debate. The aim of this study was to identify if FVH combined with the other markers improved favorable outcome prediction of acute infarctions in patients with unilateral acute internal carotid artery (ICA) occlusion. METHODS Consecutive 68 adult acute middle cerebral artery (MCA) territory infarction patients caused by acute ICA occlusion, including favorable (n = 38, mRS ≤ 2) and unfavorable (n = 30, mRS > 2) groups, were enrolled in this retrospective analysis. The diagnostic efficiency of favorable clinical outcome of FVH-DWI mismatch was compared with those of DWI lesions volumetry and the combined marker of FVH-DWI mismatch and other factors. RESULTS There were more prominent FVH-DWI mismatch (≥ 3 sections) (84%), less atrial fibrillation (AFib) (13%), and more tandem MCA normal or mild stenosis (63%) in favorable outcome group than those (30%, 40%, and 27%, respectively) in unfavorable group. Univariate and multivariate analyses showed that the prominent FVH-DWI mismatch was the positive predictive factor for favorable outcome (OR = 2.643 and 3.200). Prominent FVH-DWI mismatch, in combination with tandem MCA normal or mild stenosis, and absence of Afib, had better performance (AUC = 0.875) than that of initial DWI lesion volumetry (AUC = 0.854) and any other single factor (AUC = 0.634~0.820) in predicting favorable outcome. CONCLUSIONS Prominent FVH-DWI mismatch was associated with favorable outcome in acute infarctions in unilateral ICA occlusion patients. Its predictive performance would be improved when combined with the assessment of tandem lesions of MCA and AFib.
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Affiliation(s)
- Tao Yuan
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Guoli Ren
- Department of Medical Imaging, Liaocheng People's Hospital, Liaocheng, China
| | - Xianning Hu
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Lina Geng
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Xueqing Li
- Department of Medical Imaging, Lingshou County People's Hospital, Shijiazhuang, China
| | - Shuang Xia
- Department of Radiology, Tianjin First Central Hospital, Tianjin, China
| | - Guanmin Quan
- Department of Medical Imaging, The Second Hospital of Hebei Medical University, Shijiazhuang, China.
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Li CC, Hao XZ, Tian JQ, Yao ZW, Feng XY, Yang YM. Predictors of short-term outcome in patients with acute middle cerebral artery occlusion: unsuitability of fluid-attenuated inversion recovery vascular hyperintensity scores. Neural Regen Res 2018; 13:69-76. [PMID: 29451209 PMCID: PMC5840994 DOI: 10.4103/1673-5374.224375] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Fluid-attenuated inversion recovery (FLAIR) vascular hyperintensity (FVH) is used to assess leptomeningeal collateral circulation, but clinical outcomes of patients with FVH can be very different. The aim of the present study was to assess a FVH score and explore its relationship with clinical outcomes. Patients with acute ischemic stroke due to middle cerebral artery M1 occlusion underwent magnetic resonance imaging and were followed up at 10 days (National Institutes of Health Stroke Scale) and 90 days (modified Rankin Scale) to determine short-term clinical outcomes. Effective collateral circulation indirectly improved recovery of neurological function and short-term clinical outcome by extending the size of the pial penumbra and reducing infarct lesions. FVH score showed no correlation with 90-day functional clinical outcome and was not sufficient as an independent predictor of short-term clinical outcome.
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Affiliation(s)
- Chan-Chan Li
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiao-Zhu Hao
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Jia-Qi Tian
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Zhen-Wei Yao
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xiao-Yuan Feng
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yan-Mei Yang
- Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
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Friedrich B, Lobsien D, Wunderlich S, Maegerlein C, Pree D, Hoffmann KT, Zimmer C, Kaesmacher J. Endovascular Stroke Treatment: How Far Downstream Should We Go? Cardiovasc Intervent Radiol 2017; 41:55-62. [PMID: 29075880 DOI: 10.1007/s00270-017-1830-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2017] [Accepted: 10/19/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Endovascular thrombectomy has become the de facto standard in the treatment of large vessel occlusion. Previously, a correlation between good outcome and the occlusion site, measured by the 'distance to thrombus' (DT)-as the distance from the carotid T to the beginning of the thrombus-after thrombolysis could be shown. In the present study, we analyze the differences between the chances of a good outcome in respect of DT between patients treated endovascularly or intravenously. METHODS A dual-center database analysis including patients with stroke due to occlusion of the middle cerebral artery (MCA) was performed. Inclusion criteria were a completed treatment and full documentation of the clinical course. DT was measured in pre-treatment images. DT was correlated with the mRS at 90 days stratified according to the different treatment methods. RESULTS A total of 280 patients could be included. We were able to show a correlation between the chances of good clinical outcome and the occlusion site measured by DT after i.v. thrombolysis. The outcome after endovascular treatment showed no correlation with DT (p = 0.227). After a DT of 26 mm, the chances of a good outcome after i.v. thrombolysis exceeded those after endovascular treatment. CONCLUSION In patients with MCA occlusion, the probability for a good outcome after endovascular treatment is independent of the occlusion site in contrast to the treatment with i.v. thrombolysis. If the occlusion occurred in the periphery of the M2 region (DT > 26 mm), i.v. thrombolysis alone was superior to endovascular treatment in achieving a good outcome.
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Affiliation(s)
- Benjamin Friedrich
- Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 80675, Munich, Germany.
| | - Donald Lobsien
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Christian Maegerlein
- Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 80675, Munich, Germany
| | - David Pree
- Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 80675, Munich, Germany
| | | | - Claus Zimmer
- Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 80675, Munich, Germany
| | - Johannes Kaesmacher
- Department of diagnostic and interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 80675, Munich, Germany
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Leng X, Lan L, Liu L, Leung TW, Wong KS. Good collateral circulation predicts favorable outcomes in intravenous thrombolysis: a systematic review and meta-analysis. Eur J Neurol 2016; 23:1738-1749. [PMID: 27478977 DOI: 10.1111/ene.13111] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Accepted: 06/27/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Baseline collateral status has been correlated with outcomes of acute ischaemic stroke patients receiving intravenous thrombolysis (IVT) in previous studies. We carried out the current systematic review and meta-analysis to synthesize currently available evidence regarding such correlations. METHODS Full-text articles published since 2000 were retrieved and screened. The overall effect sizes of good versus poor collateral status over a series of outcomes and certain baseline features were estimated by random-effects models and presented in risk ratios (RRs) or mean differences. RESULTS Overall, 28 (3057 patients) and 14 (1584 patients) studies were included in qualitative and quantitative synthesis, respectively. Compared with poor pre-treatment collateral status, good collaterals showed a beneficial effect over the primary outcome of a favorable functional outcome at 3 or 6 months [RR, 2.45; 95% confidence interval, 1.94-3.09; P < 0.001] in acute ischaemic stroke patients receiving IVT treatment. However, such an effect tended to be different between studies with prescribed time windows of 3, 4.5 and > 4.5 h (up to 7 h), with the RRs being 2.21, 2.48 and 5.00, respectively (I2 = 53%). Good pre-treatment collaterals were also associated with a smaller infarct size at baseline, and a lower rate of symptomatic intracranial hemorrhage and a higher rate of neurological improvement early after IVT treatment. CONCLUSIONS The present study has demonstrated the prognostic value of baseline collateral circulation for outcomes of acute ischaemic stroke patients receiving intravenous reperfusion therapies, studied with different time windows of up to 7 h after ictus for IVT therapy.
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Affiliation(s)
- X Leng
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - L Lan
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - L Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - T W Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
| | - K S Wong
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong
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Gawlitza M, Friedrich B, Hobohm C, Schaudinn A, Schob S, Quäschling U, Hoffmann KT, Lobsien D. Distance to Thrombus in Acute Middle Cerebral Artery Occlusion Predicts Target Mismatch and Ischemic Penumbra. J Stroke Cerebrovasc Dis 2015; 25:298-305. [PMID: 26542822 DOI: 10.1016/j.jstrokecerebrovasdis.2015.09.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/11/2015] [Accepted: 09/26/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE In patients with occlusion of the middle cerebral artery (MCA) treated by intravenous thrombolysis (IVT), the distance to thrombus (DT) has been proposed as a predictor of outcome. The purpose of the present study was to investigate how DT relates to dynamic susceptibility contrast perfusion metrics. METHODS Retrospective analysis was undertaken of patients who were diagnosed with acute MCA occlusion by magnetic resonance imaging and treated with IVT. Volumes of time-to-maximum (Tmax) perfusion deficits and diffusion-weighted imaging (DWI) lesions, diffusion-perfusion mismatch volumes, and the presence of target mismatch were determined. Correlations between the above stoke measures and DT were then calculated. RESULTS Fifty-five patients were included. DT showed significant inverse correlations with Tmax greater than 4, 6, 8, and 10 seconds, respectively, and mismatch volumes. Using the DT group median (14 mm) as a separator, significant intergroup differences were observed for Tmax greater than 4, 6, and 8 seconds, respectively, and for mismatch volumes. Grouping DT into quartiles showed significant intergroup differences regarding mismatch volumes and Tmax values greater than 4 and 6 seconds. Binary logistic regression identified DT (odds ratio [OR] = .89; 95% confidence interval [CI], .81-.99) and DWI lesion volumes (OR = .92; 95% CI, .86-.97) as independent predictors of target mismatch. A low DT predicted target mismatch with an area under the curve of .69. CONCLUSIONS DT correlates inversely with Tmax perfusion deficits and mismatch volumes and acts as an independent predictor of target mismatch.
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Affiliation(s)
- Matthias Gawlitza
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany.
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Carsten Hobohm
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | - Alexander Schaudinn
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Stefan Schob
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Ulf Quäschling
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | | | - Donald Lobsien
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
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