...due to insufficient prospective cohort enrollment, authors added patients from a retrospective cohort, and then aggregated the data for statistical analysis. ...the gold standard was a ...semi-quantitative MRA method for MCA stenosis evaluation. ...it has been proposed to consider the mean velocity curve of the spectrum, which would better reflect the flow in the artery than the maximal contour curve. ...unlike neurologists and neuro-intensivists, hematology-pediatricians who monitor vascular diseases related to sickle cell disease most often use mean velocity contours-based indices 5.
Summary Background The IMS III trial did not show a clinical benefit of endovascular treatment compared with intravenous alteplase (recombinant tissue plasminogen activator) alone for moderate or ...severe ischaemic strokes. Late reperfusion of tissue that was no longer salvageable could be one explanation, as suggested by previous exploratory studies that showed an association between time to reperfusion and good clinical outcome. We sought to validate this association in a preplanned analysis of data from the IMS III trial. Methods We used data for patients with complete proximal arterial occlusions in the anterior circulation who received endovascular treatment and achieved angiographic reperfusion (score on Thrombolysis in Cerebral Infarction scale of grade 2–3) during the endovascular procedure (within 7 h of symptom onset). We used logistic regression to model good clinical outcome (defined as a modified Rankin Scale score of 0–2 at 3 months) as a function of the time to reperfusion. We prespecified variables to be considered for adjustment, including age, baseline National Institutes of Health Stroke Scale score, sex, and baseline blood glucose concentration. Findings Of 240 patients who were otherwise eligible for inclusion in our analysis, 182 (76%) achieved angiographic reperfusion. Mean time from symptom onset to reperfusion (ie, procedure end) was 325 min (SD 52). Increased time to reperfusion was associated with a decreased likelihood of good clinical outcome (unadjusted relative risk for every 30-min delay 0·85 95% CI 0·77–0·94; adjusted relative risk 0·88 0·80–0·98). Interpretation Delays in time to angiographic reperfusion lead to a decreased likelihood of good clinical outcome in patients after moderate to severe stroke. Rapid reperfusion could be crucial for the success of future acute endovascular trials. Funding US National Institutes of Health and National Institute of Neurological Disorders and Stroke.
The occurrence of both ischaemic (IS) and haemorrhagic stroke in patients on anticoagulation is a major issue due to the frequency of their prescriptions in westernised countries and the expected ...impact of anticoagulant activity on recanalization during an IS or on the outcomes associated with intracerebral haemorrhage (ICH). Several guidelines are available but sometimes differ in their conclusions or regarding specific issues, and their application in routine emergency settings may be limited by particular individual issues or heterogeneous local specificities.
Based on the current guidelines and additional published data, the algorithms proposed in this paper aim to help the decision-making process regarding stroke management in the setting of concurrent anticoagulants by addressing specific clinical situations based on clinical variables commonly encountered in real-world practise.
For patients on non-vitamin K oral anticoagulants, reversion can be achieved with specific antidotes, but only idarucizumab, the specific dabigatran antidote, is indicated in both IS and ICH. Due to the low risk of a prothrombotic effect, idarucizumab can be immediately used in IS patients eligible for thrombolysis before the dabigatran concentration is known. To optimise ICH management, the time since symptom onset, with thresholds proposed at 6 and 9 hours based on the expected timing of haematoma expansion, could also to be taken into account.
Anticoagulant reversal in patients presenting with a stroke remains a major issue, and algorithms based on a step-by-step approach may be useful for clinical practise. Real-life studies strongly support the benefits of idarucizumab availability in stroke units and emergency departments.
Large vessel occlusion stroke due to underlying intracranial atherosclerotic disease (ICAD-LVO) is prevalent in 10 to 30% of LVOs depending on patient factors such as vascular risk factors, race and ...ethnicity, and age. Patients with ICAD-LVO derive similar functional outcome benefit from endovascular thrombectomy as other mechanisms of LVO, but up to half of ICAD-LVO patients reocclude after revascularization. Therefore, early identification and treatment planning for ICAD-LVO are important given the unique considerations before, during, and after endovascular thrombectomy. In this review of ICAD-LVO, we propose a multistep approach to ICAD-LVO identification, pretreatment and endovascular thrombectomy considerations, adjunctive medications, and medical management. There have been no large-scale randomized controlled trials dedicated to studying ICAD-LVO, therefore this review focuses on observational studies.
Background
Innovative tools to reliably identify patients with acute stroke are needed. Peripheral monocyte subsets, that is, classical‐Mon1, intermediate‐Mon2, and non‐classical‐Mon3, with their ...activation marker expression analyzed using flow‐cytometry (FCM) could be interesting cell biomarker candidates.
Aim
To assess the inter‐operator variability in a new peripheral monocyte subset gating strategy using FCM in patients with suspected acute stroke.
Methods
In BOOST‐study (“Biomarkers‐algOrithm‐for‐strOke‐diagnoSis‐and Treatment‐resistance‐prediction,” NCT04726839), patients ≥18 years with symptoms suggesting acute stroke within the last 24 h were included. Blood was collected upon admission to emergency unit. FCM analysis was performed using the FACS‐CANTO‐II® flow‐cytometer and Flow‐Jo™‐software. Analyzed markers were CD45/CD91/CD14/CD16 (monocyte backbone) and CD62L/CD11b/HLA‐DR/CD86/CCR2/ICAM‐1/CX3CR1/TF (activation markers). Inter‐operator agreement (starting from raw‐data files) was quantified by the measure distribution and, for each patient, the coefficient of variation (CV).
Results
Three operators analyzed 20 patient blood samples. Median inter‐operator CVs were below the pre‐specified tolerance limits (10% for Mon1 counts, 20% Mon2, Mon3 counts, 15% activation marker median‐fluorescence‐intensities). We observed a slight, but systematic, inter‐operator effect. Overall, absolute inter‐operator differences in fractions of monocyte subsets were <0.03.
Conclusion
Our gating strategy allowed monocyte subset gating with an acceptable inter‐operator variability. Although low, the inter‐operator effect should be considered in monocyte data analysis of BOOST‐patients.
The aim of this study was to identify the optimal endovascular approach in patients with acute stroke with tandem lesions.
At present, there is no consensus about the ideal technical strategy for the ...endovascular treatment of patients with acute ischemic stroke with tandem lesions of the extracranial internal carotid artery (ICA) and intracranial cerebral arteries.
This was an international, multicenter registry with a total of 482 patients with acute ischemic stroke and tandem lesions. Patients were treated by intracranial thrombectomy as well as 1 of the following 4 strategies: 1) acute carotid artery stenting of the extracranial ICA with antithrombotic agents; 2) acute carotid artery stenting of the extracranial ICA without antithrombotic agents; 3) balloon angioplasty of the extracranial ICA; and 4) intracranial thrombectomy alone. The main outcome endpoints of the study were the degree of recanalization and the 90-day clinical outcome. The safety endpoints were symptomatic intracerebral hemorrhage and all causes of mortality at 90 days.
Using univariate analysis, the rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction grades 2B and 3) and favorable clinical outcome after 90 days were significantly higher after acute carotid stenting with antithrombotic therapy and thrombectomy compared with the group with thrombectomy alone. After adjusting for confounding variables, acute stenting with antithrombotic therapy was independently associated with successful recanalization (odds ratio: 2.4; 95% confidence interval: 1.25 to 4.59; p = 0.008). The rates of symptomatic intracerebral hemorrhage and 90-day mortality were comparable among all 4 treatment groups.
Acute stenting of the extracranial ICA with antithrombotic therapy in combination with intracranial thrombectomy is associated with higher recanalization rates in treatment of patients with acute stroke with tandem lesions.
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Six randomized controlled clinical trials have assessed whether mechanical thrombectomy (MT) alone is non-inferior to intravenous thrombolysis (IVT) plus MT within 4.5 hours of symptom onset in ...patients with anterior circulation large vessel occlusion (LVO) ischemic stroke and no contraindication to IVT. An expedited recommendation process was initiated by the European Stroke Organisation (ESO) and conducted with the European Society of Minimally Invasive Neurological Therapy (ESMINT) according to ESO standard operating procedure based on the GRADE system. We identified two relevant Population, Intervention, Comparator, Outcome (PICO) questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. Expert opinion was provided if insufficient evidence was available to provide recommendations based on the GRADE approach.For stroke patients with anterior circulation LVO directly admitted to a MT-capable center ('mothership') within 4.5 hours of symptom onset and eligible for both treatments, we recommend IVT plus MT over MT alone (moderate evidence, strong recommendation). MT should not prevent the initiation of IVT, nor should IVT delay MT. In stroke patients with anterior circulation LVO admitted to a center without MT facilities and eligible for IVT ≤4.5 hours and MT, we recommend IVT followed by rapid transfer to a MT capable-center ('drip-and-ship') in preference to omitting IVT (low evidence, strong recommendation). Expert consensus statements on ischemic stroke on awakening from sleep are also provided. Patients with anterior circulation LVO stroke should receive IVT in addition to MT if they have no contraindications to either treatment.
Despite successful recanalization with mechanical thrombectomy (MT) for acute anterior ischemic stroke (AAIS), the number of passes may impact clinical outcome.We analyzed the impact of more than ...three MT passes (>3) in a trial that evaluated contact aspiration (CA) versus stent retriever (SR) as the first-line technique in AAIS.
We included patients with mTICI 2b/3 recanalization after MT for isolated intracranial occlusions. The primary outcome was the percentage of patients with a 90-day modified Rankin Scale (mRS)≤2. Secondary outcomes included overall distribution of 90-day mRS, parenchymal hematoma on 24 hours' brain imaging (PH), and 90-day mortality.
Among the 281 patients included and even after adjustment on time to recanalization, significantly more patients with >3 passes had PH than patients with ≤3 passes in multivariate analysis (adjusted OR, 3.62; 95% CI, 1.55 to 8.44). When the analyses were stratified according to CA vs. SR, patients with >3 passes had a stronger risk of PH than patients with ≤3 passes, only in the SR first-line-treated group (adjusted OR, 9.24; 95% CI, 2.65 to 32.13) and not in the CA first-line-treated group (adjusted RR, 1.73; 95% CI, 0.57 to 5.19). A negative association of borderline significance (P=0.07) between >3 passes and favorable outcome was observed only in SR first-line-treated patients (adjusted OR, 0.33; 95% CI, 0.09 to 1.11).
After three passes of SR and unlike for three passes of CA, there is an increased risk of PH and a trend toward a worse clinical outcome.
Objective
Whether the time from intravenous thrombolysis (IVT) to endovascular treatment (EVT) in patients with acute ischemic stroke has an effect on the functional outcome is unknown.
Methods
The ...Endovascular Treatment in Ischemic Stroke (ETIS) registry is an ongoing, prospective, multicenter, observational study that perform EVT in France. Data were analyzed from patients treated by IVT and EVT between October 2013 and December 2018 in 6 comprehensive stroke centers. In the primary analysis, we assessed the association of time from IVT administration to start of EVT with functional outcome (measured with the modified Rankin Scale mRS), by means of ordinal logistic regression. Secondary end points included angiographic and safety outcomes.
Results
We analyzed 1,986 patients with acute ischemic stroke due to anterior circulation large vessel occlusion who underwent IVT and EVT. An increased IVT to start of EVT time was associated with a worse functional outcome at 90 days (mRS = 0–2, adjusted odds ratio OR per 30 minutes increase in time = 0.91, 95% confidence interval CI = 0.86–0.96; mRS = 0–1, adjusted OR per 30 minutes increase in time = 0.89, 95% CI = 0.84–0.94), a lower chance of modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b to 3 reperfusion (adjusted OR per 30 minutes increase in time = 0.93, 95% CI = 0.87–0.98), and an increased probability of symptomatic intracerebral hemorrhage (adjusted OR per 30 minutes increase in time = 1.09, 95% CI = 0.99–1.18).
Interpretation
These findings provide a basis for further studies to determine if the functional outcome of patients with stroke can be greatly improved by optimizing IVT to EVT times. ANN NEUROL 2021;89:511–519
Summary Background Diagnosis and treatment of cerebral and retinal transient ischaemic attacks (TIAs) are often delayed by the lack of immediate access to a dedicated TIA clinic. We evaluated the ...effects of rapid assessment of patients with TIA on clinical decision making, length of hospital stay, and subsequent stroke rates. Methods We set up SOS-TIA, a hospital clinic with 24-h access. Patients were admitted if they had sudden retinal or cerebral focal symptoms judged to relate to ischaemia and if they made a total recovery. Assessment, which included neurological, arterial, and cardiac imaging, was within 4 h of admission. A leaflet about TIA with a toll-free telephone number for SOS-TIA was sent to 15 000 family doctors, cardiologists, neurologists, and ophthalmologists in Paris and its administrative region. Endpoints were stroke within 90 days, and stroke, myocardial infarction, and vascular death within 1 year. Findings Between January, 2003, and December, 2005, we admitted 1085 patients with suspected TIA; 574 (53%) were seen within 24 h of symptom onset. 701 (65%) patients had confirmed TIA or minor stroke, and 144 (13%) had possible TIA. 108 (17%) of the 643 patients with confirmed TIA had brain tissue damage. Median duration of symptoms was 15 min (IQR 5–75 min). Of the patients with confirmed or possible TIA, all started a stroke prevention programme, 43 (5%) had urgent carotid revascularisation, and 44 (5%) were treated for atrial fibrillation with anticoagulants. 808 (74%) of all patients seen were sent home on the same day. The 90-day stroke rate was 1·24% (95% CI 0·72–2·12), whereas the rate predicted from ABCD2 scores was 5·96%. Interpretation Use of TIA clinics with 24-h access and immediate initiation of preventive treatment might greatly reduce length of hospital stay and risk of stroke compared with expected risk.
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