Objective Among patients with symptomatic carotid artery stenosis, carotid artery stenting (CAS) is associated with a higher risk of periprocedural stroke or death than carotid endarterectomy (CEA). ...Uncertainty remains whether the balance of risk changes with time since the most recent ischemic event. Methods We investigated the association of time between the qualifying ischemic event and treatment (0-7 days, 8-14 days, and >14 days) with the risk of stroke or death within 30 days after CAS or CEA in a pooled analysis of data from individual patients randomized in the Endarterectomy vs Angioplasty in Patients with Symptomatic Severe Carotid Stenosis (EVA-3S) trial, the Stent-Protected Angioplasty versus Carotid Endarterectomy (SPACE) trial, and the International Carotid Stenting Study (ICSS). Data were analyzed with a fixed-effect binomial regression model adjusted for source trial. Results Information on time of qualifying event was available for 2839 patients. In the first 30 days after intervention, any stroke or death occurred significantly more often in the CAS group (110/1434 7.7%) compared with the CEA group (54/1405 3.8%; crude risk ratio, 2.0; 95% confidence interval, 1.5-2.7). Patients undergoing CEA within the first 7 days of the qualifying event had the lowest periprocedural stroke or death rate (3/106 2.8%). Patients treated with CAS in the same period had a 9.4% risk of periprocedural stroke or death (13/138; risk ratio CAS vs CEA: 3.4; 95% confidence interval, 1.01-11.8; adjusted for age, sex, and type of qualifying event). Patients treated between 8 and 14 days showed a periprocedural stroke or death rate of 3.4% (7/208) and 8.1% (19/234), respectively, for CEA and CAS. The latest treatment group had 4% complications in the CEA group (44/1091) and 7.3% in the CAS group (78/1062). Conclusions The increase in risk of CAS compared with CEA appears to be greatest in patients treated within 7 days of symptoms. Early surgery might remain most effective in stroke prevention in patients with symptomatic carotid artery stenosis.
Objective To assess effect of age on response to alteplase in acute ischaemic stroke.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.Setting Collaboration between International Stroke Thrombolysis Registry (SITS-ISTR) and Virtual International Stroke Trials Archive (VISTA).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.Main outcome measures Functional outcomes at 90 days measured by score on modified Rankin scale.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; P<0.001; 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.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.
IMPORTANCE: Optimal management of sedation and airway during thrombectomy for acute ischemic stroke is controversial due to lack of evidence from randomized trials. OBJECTIVE: To assess whether ...conscious sedation is superior to general anesthesia for early neurological improvement among patients receiving stroke thrombectomy. DESIGN, SETTING, AND PARTICIPANTS: SIESTA (Sedation vs Intubation for Endovascular Stroke Treatment), a single-center, randomized, parallel-group, open-label treatment trial with blinded outcome evaluation conducted at Heidelberg University Hospital in Germany (April 2014-February 2016) included 150 patients with acute ischemic stroke in the anterior circulation, higher National Institutes of Health Stroke Scale (NIHSS) score (>10), and isolated/combined occlusion at any level of the internal carotid or middle cerebral artery. INTERVENTION: Patients were randomly assigned to an intubated general anesthesia group (n = 73) or a nonintubated conscious sedation group (n = 77) during stroke thrombectomy. MAIN OUTCOMES AND MEASURES: Primary outcome was early neurological improvement on the NIHSS after 24 hours (0-42 none to most severe neurological deficits; a 4-point difference considered clinically relevant). Secondary outcomes were functional outcome by modified Rankin Scale (mRS) after 3 months (0-6 symptom free to dead), mortality, and peri-interventional parameters of feasibility and safety. RESULTS: Among 150 patients (60 women 40%; mean age, 71.5 years; median NIHSS score, 17), primary outcome was not significantly different between the general anesthesia group (mean NIHSS score, 16.8 at admission vs 13.6 after 24 hours; difference, −3.2 points 95% CI, −5.6 to −0.8) vs the conscious sedation group (mean NIHSS score, 17.2 at admission vs 13.6 after 24 hour; difference, −3.6 points 95% CI, −5.5 to −1.7); mean difference between groups, −0.4 (95% CI, −3.4 to 2.7; P = .82). Of 47 prespecified secondary outcomes analyzed, 41 showed no significant differences. In the general anesthesia vs the conscious sedation group, substantial patient movement was less frequent (0% vs 9.1%; difference, 9.1%; P = .008), but postinterventional complications were more frequent for hypothermia (32.9% vs 9.1%; P < .001), delayed extubation (49.3% vs 6.5%; P < .001), and pneumonia (13.7% vs 3.9%; P = .03). More patients were functionally independent (unadjusted mRS score, 0 to 2 after 3 months 37.0% in the general anesthesia group vs 18.2% in the conscious sedation group P = .01). There were no differences in mortality at 3 months (24.7% in both groups). CONCLUSIONS AND RELEVANCE: Among patients with acute ischemic stroke in the anterior circulation undergoing thrombectomy, conscious sedation vs general anesthesia did not result in greater improvement in neurological status at 24 hours. The study findings do not support an advantage for the use of conscious sedation. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02126085
Failure of early neurological improvement (fENI) despite successful mechanical thrombectomy in the anterior circulation is a clinically frequent occurrence. Purpose of this analysis was to define ...independent clinical, radiological, laboratory, or procedural predictors for fENI.
Retrospective single-center analysis of patients treated for acute ischemic stroke in the anterior circulation ensuing successful mechanical thrombectomy between January 2014 and April 2019. Patients were compared according to fENI (equal or higher National Institutes of Health Stroke Scale) and ENI (lower National Institutes of Health Stroke Scale at discharge). Thirty-eight variables were examined in multivariable analysis for association with fENI.
Five hundred forty-nine out of 1146 patients experienced successful recanalization (modified Treatment in Cerebral Ischemia 2c-3). fENI occurred in 115/549 (20.9%) patients. Independent predictors of fENI were premorbid modified Rankin Scale (odds ratio OR per point IC, 1.21 1.00-1.46,
=0.049), end-stage renal failure (OR IC, 12.18 2.01-73.63,
=0.007), admission glucose (OR IC, 1.018 1.004-1.013 per mg/dL,
=0.001), bridging IV lysis (OR IC, 0.57 0.35-0.93,
: 0.024), time from groin puncture to final recanalization (OR IC, 1.004 1.001-1.007 per minute,
=0.015), general anesthesia during mechanical thrombectomy (OR, 2.41 1.43-4.08,
<0.001), symptomatic intracranial hemorrhage (OR CI, 6.81 1.84-25.16,
=0.004), and follow-up Alberta Stroke Program Early CT Score (OR IC, 0.76 0.69-0.84 per point,
<0.001). In a secondary analysis, involvement of the regions internal capsule, M4 and M5 (motor cortex) were further independent predictors for fENI. Patients with ENI were more likely to experience a good outcome (modified Rankin Scale on day 90, 0-2: n=229/435 52.8% versus n=13/115 11.3%;
<0.001).
The extent of infarction and the involvement of motor cortex and internal capsule as well as higher premorbid modified Rankin Scale, end-stage renal failure, high glucose level on admission, absence of bridging IV lysis, general anesthesia, and a longer therapy interval are presumably independent predictors for fENI in patients with successful mechanical thrombectomy.
Purpose of Review
Provide a current overview regarding the optimal strategy for managing patients with asymptomatic carotid artery stenosis.
Recent Findings
Carotid endarterectomy (CEA) and carotid ...artery stenting (CAS) reduce long-term stroke risk in asymptomatic patients. However, CAS is associated with a higher risk of peri-procedural stroke. Improvements in best medical therapy (BMT) have renewed uncertainty regarding the extent to which results from older randomised controlled trials (RCTs) comparing outcomes following carotid intervention can be generalised to modern medical practise.
Summary
‘Average surgical risk’ patients with an asymptomatic carotid artery stenosis of 60–99% and increased risk of late stroke should be considered for either CEA or CAS. In patients deemed ‘high risk’ for surgery, CAS is indicated. Use of an anti-platelet, anti-hypertensive and statin, with strict glycaemic control, is recommended. Results from ongoing large, multicentre RCTs comparing CEA, CAS and BMT will provide clarity regarding the optimal management of patients with asymptomatic carotid artery stenosis.
BACKGROUND AND PURPOSE—Thrombosis of cerebral veins and sinus (cerebral venous thrombosis) is a rare stroke pathogenesis. Pharmaceutical treatment is restricted to heparin and oral anticoagulation ...with vitamin K antagonists (VKAs).
METHODS—Between January 2012 and December 2013, we recorded data from our patients with cerebral venous thrombosis. The modified Rankin scale was used to assess clinical severity; excellent outcome was defined as modified Rankin scale 0 to 1. Recanalization was assessed on follow-up MR angiography. Patients were then divided into 2 treatment groupsphenprocoumon (VKA) and a novel factor Xa inhibitor. Clinical and radiological baseline data, outcome, recanalization status, and complications were retrospectively compared.
RESULTS—Sixteen patients were included, and 7 were treated with rivaroxaban. Overall outcome was excellent in 93.8%, and all patients showed at least partial recanalization. No statistical significant differences were found between the groups, except the use of heparin before start of oral anticoagulation (P=0.03). One patient in the VKA and 2 patients in the factor Xa inhibitor group had minor bleeding (P=0.55) within the median (range) follow-up of 8 months (5–26).
CONCLUSIONS—Factor Xa inhibitor showed a similar clinical benefit as VKA in the treatment of cerebral venous thrombosis. Further systematic prospective evaluation is warranted.
Purpose
Intracranial hemorrhage (ICH) is a potentially severe complication after mechanical thrombectomy (MT). Here, we investigated risk factors for the occurrence of any and symptomatic ICH after ...MT due to large-vessel occlusion of the anterior circulation.
Methods
Consecutive patients with acute ischemic anterior circulation stroke with large-vessel occlusion undergoing MT were analyzed. ICH was categorized according to the Heidelberg Bleeding Classification. Forty-three procedural and clinical parameters were analyzed using univariate tests and multivariate logistic regressions.
Results
Of 612 patients, any ICH was detected in 195 (31.9%), while 27 (4.4%) developed a symptomatic ICH. Infarct size > 1/3 of vascular territory in control imaging (OR 2.18, 95% CI 1.45–3.21), higher serum glucose levels (OR 1.23 for change of 15 units mg/dL, 95% CI 1.10–1.39), and higher thrombectomy maneuver count (OR 1.21, 95% CI 1.11–1.32) were significantly associated with a higher risk of developing any ICH compared to no ICH. Wake-up strokes (OR 3.99, 95% CI 1.38–11.60), transfer from an external clinic (OR 3.04, 95% CI 1.24–7.48), and higher serum glucose levels (OR 1.22 for change of 15 units mg/dL, 95% CI 1.05–1.42) were revealed as independent risk factors for development of symptomatic ICH compared to no symptomatic ICH. Patients with no infarct demarcation (OR 0.10, 95% CI 0.01–0.80) and complete recanalization (OR 0.57, 95% CI 0.37–0.86) showed a lower risk of developing any ICH.
Conclusion
Wake-up strokes and patients who are treated within a drip-and-ship concept are especially vulnerable for symptomatic ICH, while complete recanalization, contrary to subtotal recanalization only, was revealed as a protective factor against ICH.
Summary Background Age was reported to be an effect-modifier in four randomised controlled trials comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA), with better CEA outcomes ...than CAS outcomes noted in the more elderly patients. We aimed to describe the association of age with treatment differences in symptomatic patients and provide age-specific estimates of the risk of stroke and death within narrow (5 year) age groups. Methods In this meta-analysis, we analysed individual patient-level data from four randomised controlled trials within the Carotid Stenosis Trialists' Collaboration (CSTC) involving patients with symptomatic carotid stenosis. We included only trials that randomly assigned patients to CAS or CEA and only patients with symptomatic stenosis. We assessed rates of stroke or death in 5-year age groups in the periprocedural period (between randomisation and 120 days) and ipsilateral stroke during long-term follow-up for patients assigned to CAS or CEA. We also assessed differences between CAS and CEA. All analyses were done on an intention-to-treat basis. Findings Collectively, 4754 patients were randomly assigned to either CEA or CAS treatment in the four studies. 433 events occurred over a median follow-up of 2·7 years. For patients assigned to CAS, the periprocedural hazard ratio (HR) for stroke and death in patients aged 65–69 years compared with patients younger than 60 years was 2·16 (95% CI 1·13–4·13), with HRs of roughly 4·0 for patients aged 70 years or older. We noted no evidence of an increased periprocedural risk by age group in the CEA group (p=0·34). These changes underpinned a CAS-versus CEA periprocedural HR of 1·61 (95% CI 0·90–2·88) for patients aged 65–69 years and an HR of 2·09 (1·32–3·32) for patients aged 70–74 years. Age was not associated with the postprocedural stroke risk either within treatment group (p≥0·09 for CAS and 0·83 for CEA), or between treatment groups (p=0·84). Interpretation In these RCTs, CEA was clearly superior to CAS in patients aged 70–74 years and older. The difference in older patients was almost wholly attributable to increasing periprocedural stroke risk in patients treated with CAS. Age had little effect on CEA periprocedural risk or on postprocedural risk after either procedure. Funding None.
IMPORTANCE: General anesthesia during thrombectomy for acute ischemic stroke has been associated with poor neurological outcome in nonrandomized studies. Three single-center randomized trials ...reported no significantly different or improved outcomes for patients who received general anesthesia compared with procedural sedation. OBJECTIVE: To detect differences in functional outcome at 3 months between patients who received general anesthesia vs procedural sedation during thrombectomy for anterior circulation acute ischemic stroke. DATA SOURCE: MEDLINE search for English-language articles published from January 1, 1980, to July 31, 2019. STUDY SELECTION: Randomized clinical trials of adults with a National Institutes of Health Stroke Scale score of at least 10 and anterior circulation acute ischemic stroke assigned to receive general anesthesia or procedural sedation during thrombectomy. DATA EXTRACTION AND SYNTHESIS: Individual patient data were obtained from 3 single-center, randomized, parallel-group, open-label treatment trials with blinded end point evaluation that met inclusion criteria and were analyzed using fixed-effects meta-analysis. MAIN OUTCOMES AND MEASURES: Degree of disability, measured via the modified Rankin Scale (mRS) score (range 0-6; lower scores indicate less disability), analyzed with the common odds ratio (cOR) to detect the ordinal shift in the distribution of disability over the range of mRS scores. RESULTS: A total of 368 patients (mean SD age, 71.5 12.9 years; 163 44.3% women; median interquartile range National Institutes of Health Stroke Scale score, 17 14-21) were included in the analysis, including 183 (49.7%) who received general anesthesia and 185 (50.3%) who received procedural sedation. The mean 3-month mRS score was 2.8 (95% CI, 2.5-3.1) in the general anesthesia group vs 3.2 (95% CI, 3.0-3.5) in the procedural sedation group (difference, 0.43 95% CI, 0.03-0.83; cOR, 1.58 95% CI, 1.09-2.29; P = .02). Among prespecified adverse events, only hypotension (decline in systolic blood pressure of more than 20% from baseline) (80.8% vs 53.1%; OR, 4.26 95% CI, 2.55-7.09; P < .001) and blood pressure variability (systolic blood pressure >180 mm Hg or <120 mm Hg) (79.7 vs 62.3%; OR, 2.42 95% CI, 1.49-3.93; P < .001) were significantly more common in the general anesthesia group. CONCLUSIONS AND RELEVANCE: Among patients with acute ischemic stroke involving the anterior circulation undergoing thrombectomy, the use of protocol-based general anesthesia, compared with procedural sedation, was significantly associated with less disability at 3 months. These findings should be interpreted tentatively, given that the individual trials examined were single-center trials and disability was the primary outcome in only 1 trial.
IMPORTANCE: Advanced imaging for patient selection in mechanical thrombectomy is not widely available. OBJECTIVE: To compare the clinical outcomes of patients selected for mechanical thrombectomy by ...noncontrast computed tomography (CT) vs those selected by computed tomography perfusion (CTP) or magnetic resonance imaging (MRI) in the extended time window. DESIGN, SETTING, AND PARTICIPANTS: This multinational cohort study included consecutive patients with proximal anterior circulation occlusion stroke presenting within 6 to 24 hours of time last seen well from January 2014 to December 2020. This study was conducted at 15 sites across 5 countries in Europe and North America. The duration of follow-up was 90 days from stroke onset. EXPOSURES: Computed tomography with Alberta Stroke Program Early CT Score, CTP, or MRI. MAIN OUTCOMES AND MEASURES: The primary end point was the distribution of modified Rankin Scale (mRS) scores at 90 days (ordinal shift). Secondary outcomes included the rates of 90-day functional independence (mRS scores of 0-2), symptomatic intracranial hemorrhage, and 90-day mortality. RESULTS: Of 2304 patients screened for eligibility, 1604 patients were included, with a median (IQR) age of 70 (59-80) years; 848 (52.9%) were women. A total of 534 patients were selected to undergo mechanical thrombectomy by CT, 752 by CTP, and 318 by MRI. After adjustment of confounders, there was no difference in 90-day ordinal mRS shift between patients selected by CT vs CTP (adjusted odds ratio aOR, 0.95 95% CI, 0.77-1.17; P = .64) or CT vs MRI (aOR, 0.95 95% CI, 0.8-1.13; P = .55). The rates of 90-day functional independence (mRS scores 0-2 vs 3-6) were similar between patients selected by CT vs CTP (aOR, 0.90 95% CI, 0.7-1.16; P = .42) but lower in patients selected by MRI than CT (aOR, 0.79 95% CI, 0.64-0.98; P = .03). Successful reperfusion was more common in the CT and CTP groups compared with the MRI group (474 88.9% and 670 89.5% vs 250 78.9%; P < .001). No significant differences in symptomatic intracranial hemorrhage (CT, 42 8.1%; CTP, 43 5.8%; MRI, 15 4.7%; P = .11) or 90-day mortality (CT, 125 23.4%; CTP, 159 21.1%; MRI, 62 19.5%; P = .38) were observed. CONCLUSIONS AND RELEVANCE: In patients undergoing proximal anterior circulation mechanical thrombectomy in the extended time window, there were no significant differences in the clinical outcomes of patients selected with noncontrast CT compared with those selected with CTP or MRI. These findings have the potential to widen the indication for treating patients in the extended window using a simpler and more widespread noncontrast CT–only paradigm.
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