For thrombectomy, some stroke centres have started to use two stents simultaneously instead of only one to achieve better recanalisation rates, i.e. a double stentriever (DS) technique. The first ...observations regarding this new technique are promising. We aim to report our experience in DS at the acute phase of stroke, compare with the single stentriever technique.
We included consecutive individuals undergoing mechanical thrombectomy in the setting of acute ischemic stroke associated to a large vessel occlusion (LVO) or medium vessel occlusion (MeVO) in the anterior circulation. Individuals were included between 01.2022 and 07.2023. We excluded individuals <18 years old, those who were treated beyond 24h from last proof of good health and those who were not treated with stentriever as a first-line recanalization strategy. We compared patients undergoing double-stentriever (DS) technique for first-pass strategy vs single-stentriever (SS) technique for first-pass strategy. For the primary outcome analysis, we assessed first-pass complete recanalization (eTICI 2c-3) applying ordinal regression analyses using other prognostic co-variates. Secondary safety outcomes included procedure-related complications, early neurologic deterioration of ischemic origin (ENDi) and symptomatic intracerebral bleeding (sICH). Secondary functional outcomes included 24h-NIHSS and 3 month modified Rankin Scale (mRS). Complications such as procedural perforation, dissection, bleedings, embolization, access complication and/or reocclusion were also assessed as a dichotomized variable. Ethical commission approval and individual consent were not required according to the Swiss Human Research Act because all local data were anonymized before analysis, and because this quality assessment project aimed at the evaluation of safety and effectiveness of revascularisation treatment in current clinical practice.
Among 187 consecutive people (median age 76 (IQR= 65-83), 97/187 (52 % female, median admission NIHSS 14 (IQR=7-19)). Among them, 39 (26%) were treated with first pass DS and 148 patients (74%) with first pass SS. Within the SS group, 16 patients had rescue DS. First-pass complete recanalization (eTICI 2c-3) was achieved in 29/39 (74%) individuals treated with DS technique compared to 63/148 (43%) receiving SS technique. Procedural complications were seen in 5/39 (13%) in the DS group vs 39/148 (26%) with SS. ENDi was evidenced in 3/39 (8%) with DS compared to 18/148 (12%) with SS. sICH according to ECASSII definition was seen in 2/39 (5%) in DS compared to 8/148 (5%) in the SS group.
We dramatically increase the rate of first pass eTICI 2c/3 with DS. We didn't observe more complication rate during DS technique. Prospective randomized controlled trials are needed to support our conclusions.
Background and purpose
Demographics, clinical characteristics, stroke mechanisms and long‐term outcomes were compared between acute ischaemic stroke (AIS) patients with active cancer (AC) versus ...non‐cancer patients.
Methods
Using data from 2003 to 2021 in the Acute STroke Registry and Analysis of Lausanne, a retrospective cohort study was performed comparing patients with AC, including previously known and newly diagnosed cancers, with non‐cancer patients. Patients with inactive cancer were excluded. Outcomes were the modified Rankin Scale (mRS) score at 3 months, death and cerebrovascular recurrences at 12 months before and after propensity score matching.
Results
Amongst 6686 patients with AIS, 1065 (15.9%) had a history of cancer. After excluding 700 (10.4%) patients with inactive cancer, there were 365 (5.5%) patients with AC and 5621 (84%) non‐cancer AIS patients. Amongst AC patients, 154 (42.2%) strokes were classified as cancer related. In multivariable analysis, patients with AC were older (adjusted odds ratio aOR 1.02, 95% confidence interval CI 1.00–1.03), had fewer vascular risk factors and were 48% less likely to receive reperfusion therapies (aOR 0.52, 95% CI 0.35–0.76). Three‐month mRS scores were not different in AC patients (aOR 2.18, 95% CI 0.96–5.00). At 12 months, death (adjusted hazard ratio 1.91, 95% CI 1.50–2.43) and risk of cerebrovascular recurrence (sub‐distribution hazard ratio 1.68, 95% CI 1.22–2.31) before and after propensity score matching were higher in AC patients.
Conclusions
In a large institutional registry spanning nearly two decades, AIS patients with AC had less past cerebrovascular disease but a higher 1‐year risk of subsequent death and cerebrovascular recurrence compared to non‐cancer patients. Antithrombotic medications at discharge may reduce this risk in AC patients.
Background and aims
Only a minority of patients with Embolic Stroke of Undetermined Source (ESUS) receive prolonged cardiac monitoring despite current recommendations. The identification of ESUS ...patients who have low probability of new diagnosis of atrial fibrillation (AF) could potentially support a strategy of more individualized allocation of available resources and hence, increase their diagnostic yield. We aimed to develop a tool that can identify ESUS patients who have low probability of new incident AF.
Methods
We performed multivariate stepwise regression in a pooled dataset of consecutive ESUS patients from three prospective stroke registries to identify predictors of new incident AF. The coefficient of each independent covariate of the fitted multivariable model was used to generate an integer-based point scoring system.
Results
Among 839 patients (43.1% women, median age 67.0 years) followed-up for a median of 24.3 months (2999 patient-years), 125 (14.9%) had new incident AF. The proposed score assigns 3 points for age ≥ 60 years; 2 points for hypertension; −1 point for left ventricular hypertrophy reported at echocardiography; 2 points for left atrial diameter >40 mm; −3 points for left ventricular ejection fraction <35%; 1 point for the presence of any supraventricular extrasystole recorded during all available 12-lead standard electrocardiograms performed during hospitalization for the ESUS; −2 points for subcortical infarct; −3 points for the presence of non-stenotic carotid plaques. The rate of new incident AF during follow-up was 1.97% among the 42.3% of the cohort who had a score of ≤0, compared to 26.9% in patients with > 0 (relative risk: 13.7, 95%CI: 5.9--31.5). The area under the curve of the score was 84.8% (95%CI: 79.9--86.9%). The sensitivity and negative predictive value of a score of ≤0 for new incident AF during follow-up were 94.9% (95%CI: 89.3--98.1%) and 98.0% (95%CI: 95.8--99.3%), respectively.
Conclusions
The proposed AF-ESUS score has high sensitivity and high negative predictive value to identify ESUS patients who have low probability of new incident AF. Patients with a score of 1 or more may be better candidates for prolonged automated cardiac monitoring.
Clinical trial registration
URL: https://www.clinicaltrials.gov/ Unique identifier: NCT02766205.
Objective
The aim was to evaluate, in patients with atrial fibrillation (AF) and acute ischemic stroke, the association of prior anticoagulation with vitamin K antagonists (VKAs) or direct oral ...anticoagulants (DOACs) with stroke severity, utilization of intravenous thrombolysis (IVT), safety of IVT, and 3‐month outcomes.
Methods
This was a cohort study of consecutive patients (2014–2019) on anticoagulation versus those without (controls) with regard to stroke severity, rates of IVT/mechanical thrombectomy, symptomatic intracranial hemorrhage (sICH), and favorable outcome (modified Rankin Scale score 0–2) at 3 months.
Results
Of 8,179 patients (mean SD age, 79.8 9.6 years; 49% women), 1,486 (18%) were on VKA treatment, 1,634 (20%) on DOAC treatment at stroke onset, and 5,059 controls. Stroke severity was lower in patients on DOACs (median National Institutes of Health Stroke Scale 4, interquartile range 2–11) compared with VKA (6, 2–14) and controls (7, 3–15, p < 0.001; quantile regression: β −2.1, 95% confidence interval CI −2.6 to −1.7). The IVT rate in potentially eligible patients was significantly lower in patients on VKA (156 of 247 63%; adjusted odds ratio aOR 0.67; 95% CI 0.50–0.90) and particularly in patients on DOACs (69 of 464 15%; aOR 0.06; 95% CI 0.05–0.08) compared with controls (1,544 of 2,504 74%). sICH after IVT occurred in 3.6% (2.6–4.7%) of controls, 9 of 195 (4.6%; 1.9–9.2%; aOR 0.93; 95% CI 0.46–1.90) patients on VKA and 2 of 65 (3.1%; 0.4–10.8%, aOR 0.56; 95% CI 0.28–1.12) of those on DOACs. After adjustments for prognostic confounders, DOAC pretreatment was associated with a favorable 3‐month outcome (aOR 1.24; 1.01–1.51).
Interpretation
Prior DOAC therapy in patients with AF was associated with decreased admission stroke severity at onset and a remarkably low rate of IVT. Overall, patients on DOAC might have better functional outcome at 3 months. Further research is needed to overcome potential restrictions for IVT in patients taking DOACs. ANN NEUROL 2021;89:42–53
Endovascular treatment (EVT) in acute ischemic stroke is effective in the late time window in selected patients. However, the frequency and clinical impact of procedural complications in the early ...versus late time window has received little attention.
We retrospectively studied all acute ischemic strokes from 2015 to 2019 receiving EVT in the Acute Stroke Registry and Analysis of Lausanne. We compared the procedural EVT complications in the early (<6 hours) versus late (6-24 hours) window and correlated them with short-term clinical outcome.
Among 695 acute ischemic strokes receiving EVT (of which 202 were in the late window), 113 (16.3%) had at least one procedural complication. The frequency of each single, and for overall procedural complications was similar for early versus late EVT (16.2% versus 16.3%,
=0.90). Procedural complications lead to a significantly less favorable short-term outcome, reflected by the absence of National Institutes of Health Stroke Scale improvement in late EVT (delta-National Institutes of Health Stroke Scale-24 hours, -2.5 versus 2,
=0.01).
In this retrospective analysis of consecutive EVT, the frequency of procedural complications was similar for early and late EVT patients but very short-term outcome seemed less favorable in late EVT patients with complications.
Inflammation is emerging as an essential trigger for thrombosis. In the interplay between innate immunity and coagulation cascade, neutrophils and neutrophil extracellular traps (NETs) can promote ...thrombus formation and stabilization. In ischemic stroke, it is uncertain whether the involvement of the inflammatory component may differ in thrombi of diverse etiology. We here aimed to evaluate the presence of neutrophils and NETs in cerebral thrombi of diverse etiology retrieved by endovascular thrombectomy (EVT).
We performed a systematic histological analysis on 80 human cerebral thrombi retrieved through EVT in acute ischemic stroke patients. Thrombus composition was investigated in terms of neutrophils (MPO+ cells) and NET content (citH3+ area), employing specific immunostainings. NET plasma content was determined and compared to NET density in the thrombus.
Neutrophils and NETs were heterogeneously represented within all cerebral thrombi. Thrombi of diverse etiology did not display a statistically significant difference in the number of neutrophils (p = 0.51). However, NET content was significantly increased in cardioembolic compared to large artery atherosclerosis thrombi (p = 0.04), and the association between NET content and stroke etiology remained significant after adjusted analysis (beta coefficient = −6.19, 95%CI = −11.69 to −1.34, p = 0.01). Moreover, NET content in the thrombus was found to correlate with NET content in the plasma (p ≤ 0.001, r = 0.62).
Our study highlights how the analysis of the immune component within the cerebral thrombus, and specifically the NET burden, might provide additional insight for differentiating stroke from diverse etiologies.
Display omitted
•Human cerebral thrombi present a heterogeneous amount of neutrophils and NETs.•In retrieved thrombi, neutrophils number does not correlate with NET content.•Atheroembolic thrombi, compared to cardioembolic, have a lower content of NETs.•Thrombus NET content correlates with patient NET plasma level at stroke onset.
Background and purpose
In‐hospital strokes (IHS) are associated with longer diagnosis times, treatment delays and poorer outcomes. Strokes occurring in the stroke unit have seldom been studied. Our ...aim was to assess the management of in‐stroke‐unit ischaemic stroke (ISUS) by analysing ISUS characteristics, delays in diagnosis, treatments and outcomes.
Methods
Consecutive patients from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL), from January 2003 to June 2019, were classified as ISUS, other‐IHS or community‐onset stroke (COS). Baseline and stroke characteristics, time to imaging and time to treatment, missed treatment opportunities, treatment rates and outcomes were compared using multivariate analysis with adjustment for relevant clinical, imaging and laboratory data available in ASTRAL.
Results
Amongst the 3456 patients analysed, 138 (4.0%) were ISUS, 214 (6.2%) other‐IHS and 3104 (89.8%) COS. In multivariate analysis, patients with ISUS more frequently had known stroke onset time than other‐IHS (adjusted odds ratio aOR 2.44; 95% confidence interval CI 1.39–4.35) or COS (aOR 2.56; 95% CI 1.59–4.17), had fewer missed treatment opportunities than other‐IHS (aOR 0.22; 95% CI 0.06–0.86) and higher endovascular treatment (EVT) rates than COS (aOR 3.03; 95% CI 1.54–5.88). ISUS was associated with a favourable shift in the modified Rankin Scale at 3 months in comparison with other‐IHS (aOR 1.73; 95% CI 1.11–2.69) or COS (aOR 1.46; 95% CI 1.00–2.12).
Conclusion
In‐stroke‐unit ischaemic stroke more frequently had known stroke onset time than other‐IHS or COS, fewer missed treatment opportunities than other‐IHS and a higher EVT rate than COS. This readiness to identify and treat patients in the stroke unit may explain the better long‐term outcome of ISUS.
Patients with in‐stroke‐unit ischaemic stroke (ISUS) more frequently have known stroke onset time than other in‐hospital strokes (other‐IHS) or community‐onset strokes (COS). Patients with ISUS have fewer missed treatment opportunities than other‐IHS and higher endovascular treatment rates than COS. Patients with ISUS have better adjusted outcomes than other‐IHS and COS.
Introduction
PCT is used in the diagnosis of acute neurological syndromes, particularly stroke. We aimed to evaluate PCT abnormalities in patients with acute epileptic seizures or status epilepticus ...(SE).
Methods
We collected patients undergoing acute PCT for the suspicion of acute ischemic stroke (AIS), who received a final diagnosis of focal seizures or generalised seizures with a post-ictal deficit, with or without concomitant AIS. PCTs were retrospectively analysed for the presence of hyper- and hypoperfusion, and results correlated with delay from seizure onset, aetiology, type of seizures and the presence of electrical SE.
Results
Half of the 43 consecutively identified patients had regional PCT abnormalities—hyperperfusion in 13 (30%) and hypoperfusion in 8 (19%)—and 4 (9%) had AIS. Among patients with hyperperfusion, six (46%) had a focal deficit during imaging acquisition (two a normal clinical status, one altered consciousness and four ongoing seizure); nine (69%) of these patients had a SE; none had a stroke. All patients with hypoperfusion had focal neurological deficit; three (37%) of them a simultaneous ischemic stroke (in the remaining five, hypoperfusion was considered to be related to the seizure post-ictal phase). In the 22 with normal perfusion, 9 had a focal deficit (10 a normal clinical status, 2 altered consciousness and 1 ongoing seizure); 3 had a SE, and 1 had a stroke. Patients with SE featured a higher prevalence of hyperperfusion (9/13 69% vs. 4/30 13% without SE,
p
= 0.00).
Conclusion
In patients with acute epileptic seizures, regional hyperperfusion on PCT may suggest an ongoing or recently resolved SE, whereas hypoperfusion may be due to post-ictal state or simultaneous AIS. These observations might help attributing focal deficits to epileptic seizures rather than stroke, allowing for targeted therapy.
Abstract
Background
Atrial cardiopathy and likely pathogenic patent foramen ovale (PFO) are two potential embolic sources in patients with embolic stroke of undetermined source (ESUS). The ...relationship between these two mechanisms among ESUS patients remains unclear.
Methods
Atrial cardiopathy was defined as increased left atrial diameter index (> 23 mm/m
2
) or left atrial volume index (> 34 mL/m
2
), or PR prolongation (≥ 200 ms), or presence of supraventricular extrasystoles in the electrocardiograms performed during hospitalization for the index stoke. The presence of PFO was assessed by transthoracic echocardiography with microbubble test or by transesophageal echocardiography. The presence of PFO was considered as likely pathogenic if the Risk of Paradoxical Embolism score was 7 to 10.
Results
Among 367 ESUS patients with available information about the presence of PFO and the presence of atrial cardiopathy (median age: 61 years, 40.6% women), likely pathogenic PFO was diagnosed in 62 (16.9%) and atrial cardiopathy in 122 (33.2%). Only 4 patients (1.1%) had both likely pathogenic PFO and atrial cardiopathy. The prevalence of atrial cardiopathy was lower in patients with likely pathogenic PFO (6.5%) compared with patients with likely incidental PFO (31.2%) or without PFO (40.6%) (Pearson's chi-square test: 26.08,
p
< 0.001; adjusted odds ratio OR: 0.28, 95% confidence interval CI: 0.09–0.86). The prevalence of likely pathogenic PFO was lower in patients with atrial cardiopathy compared with patients without atrial cardiopathy (3.3% vs. 23.7%, respectively Pearson's chi-square test: 24.13,
p
< 0.001; adjusted OR: 0.2, 95% CI: 0.02–0.6).
Conclusion
The presence of atrial cardiopathy is inversely related to the presence of likely pathogenic PFO in patients with ESUS.
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