Background and purpose
The Blood Pressure Target in Acute Ischemic Stroke to Reduce Hemorrhage After Endovascular Therapy (BP TARGET) trial evaluated whether an intensive systolic blood pressure ...(SBP) target resulted in reduced rates of intracranial hemorrhage (ICH) after successful endovascular therapy (EVT) but did not assess the effect of blood pressure variability (BPV) on functional outcomes and ICH occurrence. We sought to evaluate this question in the BP TARGET trial.
Methods
We performed a post hoc analysis of the BP TARGET trial and included patients with at least 50% of blood pressure (BP) recordings during the first 24 h after EVT. BPV parameters were SBP and diastolic BP (DBP) coefficient of variation (CV), standard deviation (SD), maximum–minimum (max–min), successive variation (SV), and time rate. The primary outcome was favorable functional outcome (3‐month modified Rankin Scale between 0 and 2); the secondary outcome was the rate of ICH at 24 h.
Results
We included 290 patients (mean number of BP measures = 30.4, SD = 8.0). BPV parameters (SBPSD, SBPmax–min, SBPCV) were higher in the intensive SBP target group. Only DBP BPV parameters were associated with worse functional outcomes in the unadjusted model (DBPSD, DBPmax–min, DBPCV, and DBPSV), but not after adjustment. Higher SBPmax–min was associated with worse functional outcomes in Thrombolysis in Cerebral Infarction 2B patients (odds ratio OR = 0.62, 95% confidence interval CI = 0.38–1.02), but not in patients with complete reperfusion (OR = 1.27, 95% CI = 0.80–2.02, p for heterogeneity (phet=0.037). None of the BPV parameters was associated with ICH, regardless of the randomization group or the reperfusion grade.
Conclusions
BPV was significantly higher in the intensive SBP target group but was not associated with functional outcome or ICH.
To date, current European guidelines suggest that neurologists should monitor blood pressure (BP) noninvasively and not actively reduce systolic BP to <130 mmHg during the first 24 h after successful endovascular therapy (EVT). The present findings also suggest against BP fluctuation, notably by the intermittent use of bolus, discontinuation, and reinitiation of intravenous antihypertensive treatments such as nicardipine. Finally, further analyses are needed to clarify the impact of BP management according to the reperfusion status. Current guidelines do not suggest a distinction based on the specific reperfusion status (i.e., Thrombolysis in Cerebral Infarction 2B vs. 3) regarding BP management after successful EVT.
Background
High blood pressure (BP) is associated with worse clinical outcomes in the setting of acute ischemic stroke, but the optimal blood pressure target is still a matter of debate. We aimed to ...study the association between baseline BP and mortality in acute ischemic stroke patients treated by mechanical thrombectomy.
Methods and Results
A total of 1332 acute ischemic stroke patients treated by mechanical thrombectomy were enrolled (from January 2012 to June 2016) in the ETIS (Endovascular Treatment in Ischemic Stroke) registry. Linear and polynomial logistic regression models were used to assess the association between BP and mortality and functional outcome at 90 days. Highest mortality was found at lower and higher baseline systolic blood pressure (SBP) values following a J‐ or U‐shaped relationship, with a nadir at 157 mm Hg (95% confidence interval 143‐170). When SBP values were categorized in 10–mm Hg increments, the odds ratio for all‐cause mortality was 3.78 (95% confidence interval 1.50‐9.55) for SBP<110 mm Hg and 1.81 (95% confidence interval 1.01‐3.36) for SBP≥180 mm Hg using SBP≥150 to 160 mm Hg as reference. The rate of favorable outcome was the highest at low SBP values and lowest at high SBP values, with a nonlinear relationship; in unplanned exploratory analysis, an optimal threshold SBP≥177 mm Hg was found to predict unfavorable outcome (adjusted odds ratio 0.47; 95% confidence interval 0.31‐0.70).
Conclusion
In acute ischemic stroke patients treated by mechanical thrombectomy, baseline SBP is associated with all‐cause mortality and favorable outcome. In contrast to mortality, favorable outcome rate was the highest at low SBP values and lowest at high SBP values. Further studies are warranted to confirm these findings.
The relationship between stroke topography (ie, the regions damaged by the infarct) and functional outcome can aid clinicians in their decision-making at the acute and later stages. However, the side ...(left or right) of the stroke may also influence the identification of clinically relevant regions. We sought to determine which brain regions are associated with good functional outcome at 3 months in patients with left-sided and right-sided stroke treated by endovascular treatment using the diffusion-weighted imaging-Alberta Stroke Program Early CT Score (DWI-ASPECTS).
Patients with ischaemic stroke (n = 405) were included from the ASTER trial and Pitié-Salpêtrière registry. Blinded readers rated ASPECTS on day 1 DWI. Stepwise logistic regression analyses were performed to identify the regions related to 3-month outcome in left (n = 190) and right (n = 215) sided strokes with the modified Rankin scale (0-2) as a binary independent variable and with the 10 regions-of-interest of the DWI-ASPECTS as independent variables.
Median National Institute of Health Stroke Scale (NIHSS) at baseline was 17 (IQR: 12-20), median age was 70 years (IQR: 58-80) and median day-one NIHSS 9 (IQR: 4-18). Not all brain regions have the same weight in predicting good outcome at 3 months; moreover, these regions depend on the affected hemisphere. In left-sided strokes, the multivariate analysis revealed that preservation of the caudate nucleus, the internal capsule and the cortical M5 region were independent predictors of good outcome. In right-sided strokes, the cortical M3 and M6 regions were found to be clinically relevant.
Cortical non-motors areas related to outcome differed between left-sided and right-sided strokes. This difference might reflect the specialisation of the dominant and non-dominant hemispheres for language and attention, respectively. These results may influence decision-making at the acute and later stages.
NCT02523261.
During the last decade, significant progress has been made in understanding thrombus composition and organization in the setting of acute ischemic stroke (AIS). In particular, thrombus organization ...is now described as highly heterogeneous but with 2 preserved characteristics: the presence of (1) two distinct main types of areas in the core—red blood cell (RBC)-rich and platelet-rich areas in variable proportions in each thrombus—and (2) an external shell surrounding the core composed exclusively of platelet-rich areas. In contrast to RBC-rich areas, platelet-rich areas are highly complex and are mainly responsible for the thrombolysis resistance of these thrombi for the following reasons: the presence of platelet-derived fibrinolysis inhibitors in large amounts, modifications of the fibrin network structure resistant to the tissue plasminogen activator (tPA)-induced fibrinolysis, and the presence of non-fibrin extracellular components, such as von Willebrand factor (vWF) multimers and neutrophil extracellular traps. From these studies, new therapeutic avenues are in development to increase the fibrinolytic efficacy of intravenous (IV) tPA-based therapy or to target non-fibrin thrombus components, such as platelet aggregates, vWF multimers, or the extracellular DNA network.
3D rotational angiography (3DRA) provides high quality images of the cerebral arteriovenous malformation (AVM) nidus that can be reconstructed in 3D. However, these reconstructions are limited to ...only 3D visualization without possible interactive exploration of geometric characteristics of cerebral structures. Refined understanding of the AVM angioarchitecture prior to treatment is mandatory and vascular segmentation is an important preliminary step that allow physicians analyze the complex vascular networks and can help guide microcatheters navigation and embolization of AVM.
A deep learning method was developed for the segmentation of 3DRA images of AVM patients. The method uses a fully convolutional neural network with a U-Net-like architecture and a DenseNet backbone. A compound loss function, combining Cross Entropy and Focal Tversky, is employed for robust segmentation. Binary masks automatically generated from region-growing segmentation have been used to train and validate our model.
The developed network was able to achieve the segmentation of the vessels and the malformation and significantly outperformed the region-growing algorithm. Our experiments were performed on 9 AVM patients. The trained network achieved a Dice Similarity Coefficient (DSC) of 80.43%, surpassing other U-Net like architectures and the region-growing algorithm on the manually approved test set by physicians.
This work demonstrates the potential of a learning-based segmentation method for characterizing very complex and tiny vascular structures even when the training phase is performed with the results of an automatic or a semi-automatic method. The proposed method can contribute to the planning and guidance of endovascular procedures.
Aneurysmal subarachnoid hemorrhage (aSAH) is preferentially treated by prompt endovascular coiling, which is not available in Guadeloupe. Subsequently, patients are transferred to Paris, France ...mainland, by commercial airplane (6751 km flight) after being managed according to guidelines. This study describes the characteristics, management and outcomes related to these patients.
Retrospective observational cohort study of 148 patients admitted in intensive care unit for a suspected aSAH and transferred by airplane over a 10-year period (2010-2019).
The median interquartile range age was 53 45-64 years and 61% were female. On admission, Glasgow coma scale was 15 13-15, World Federation of Neurological Surgeons (WFNS) grading scale was 1 1-3 and Fisher scale was 4 2-4. External ventricular drainage and mechanical ventilation were performed prior to the flight respectively in 42% and 47% of patients. One-year mortality was 16% over the study period. By COX logistic regression analysis, acute hydrocephalus (hazard ratio HR 2.34, 95% confidence interval CI 0.98-5.58) prior to airplane transfer, WFNS grading scale on admission (HR 1.53, 95% CI 1.16-2.02) and age (OR 1.03, 95% 1.00-1.07) were associated with one-year mortality.
When necessary, transatlantic air transfer of patients with suspected aSAH after management according to local guidelines seems feasible and safe.
Background and Purpose Despite the widespread adoption of mechanical thrombectomy (MT) for the treatment of large vessel occlusion stroke (LVOS) in the anterior circulation, the optimal strategy for ...the treatment tandem occlusion related to cervical internal carotid artery (ICA) dissection is still debated. This individual patient pooled analysis investigated the safety and efficacy of prior intravenous thrombolysis (IVT) in anterior circulation tandem occlusion related to cervical ICA dissection treated with MT.Methods We performed a retrospective analysis of two merged prospective multicenter international real-world observational registries: Endovascular Treatment in Ischemic Stroke (ETIS) and Thrombectomy In TANdem occlusions (TITAN) registries. Data from MT performed in the treatment of tandem LVOS related to cervical ICA dissection between January 2012 and December 2019 at 24 comprehensive stroke centers were analyzed. The primary endpoint was a favorable outcome defined as 90-day modified Rankin Scale (mRS) score of 0–2.Results The study included 144 patients with tandem occlusion LVOS due to cervical ICA dissection, of whom 94 (65.3%) received IVT before MT. Prior IVT was significantly associated with a better clinical outcome considering the mRS shift analysis (common odds ratio, 2.59; 95% confidence interval CI, 1.35 to 4.93; P=0.004 for a 1-point improvement) and excellent outcome (90-day mRS 0–1) (adjusted odds ratio aOR, 4.23; 95% CI, 1.60 to 11.18). IVT was also associated with a higher rate of intracranial successful reperfusion (83.0% vs. 64.0%; aOR, 2.70; 95% CI, 1.21 to 6.03) and a lower rate of symptomatic intracranial hemorrhage (4.3% vs. 14.8%; aOR, 0.21; 95% CI, 0.05 to 0.80).Conclusions Prior IVT before MT for the treatment of tandem occlusion related to cervical ICA dissection was safe and associated with an improved 90-day functional outcome.
Mechanical thrombectomy for anterior circulation large vessel occlusion (LVO) improves functional outcome at three months. This therapeutic approach is the new gold standard, with a benefit being ...also observed in elderly patients. However, data are limited in this heterogeneous and fragile population. The objectives of this study were, first, to describe outcome after mechanical thrombectomy in a representative group of patients over 80. Second, to evaluate factors associated with a favorable functional outcome after thrombectomy for anterior circulation LVO in elderly patients (aged≥80 years).
A total of 169 patients with anterior circulation LVO referred for an endovascular treatment were included. Primary outcome evaluated functional outcome at three months. Multivariable analysis was performed to identify prognostic factors in elderly patients with pre-stroke mRS≤3.
Overall, 25.34% of patients (43/169) were functionally independent at three months (mRS≤2) and 16.57% (28/169) had a moderate functional disability (mRS=3). Mortality rate was 33.14% (56/169). At 24h, 7.1% of patients (12/169) had symptomatic hemorrhage. Male gender (P=0.033), low initial NIHSS (P=0.037), higher DWI-ASPECTS (P=0.022) and use of intravenous thrombolysis (IVT) (P=0.0193) were associated with a better functional outcome.
There is no reason to withhold mechanical thrombectomy on the basis of age alone. Small infarct core, low NIHSS, male gender and use of IVT are associated with a better functional outcome.
In the Aspiration vs. Stent Retriever for Successful Revascularization (ASTER) trial, which evaluated contact aspiration (CA) versus stent retriever (SR) use as first-line technique, the impact of ...the susceptibility vessel sign (SVS) on magnetic resonance imaging (MRI) was studied to determine its influence on trial results.
We included patients having undergone CA or SR for M1 or M2 occlusions, who were screened by MRI with T2
gradient recalled echo. Occlusions were classified as SVS (+) or SVS (-) in each randomization arm. Modified thrombolysis in cerebral infarction (mTICI) 2b, 2c, or 3 revascularization rates were recorded and clinical outcomes assessed by the overall distribution of modified Rankin scale (mRS) at 90 days.
Among the 202 patients included, 143 patients were SVS (+) (70.8%; 95% confidence interval CI, 64.5% to 77.1%). Overall, there was no difference in angiographic and clinical outcomes according to SVS status. However, compared to SR, CA achieved a lower mTICI 2c/3 rate in SVS (+) patients (risk ratio RR for CA vs. SR, 0.60; 95% CI, 0.51 to 0.71) but not in SVS (-) (RR, 1.11; 95% CI, 0.69 to 1.77;
for interaction=0.018). A significant heterogeneity in favor of superiority of first-line SR strategy in SVS (+) patients was also found regarding the overall mRS distribution (common odds ratio for CA vs. SR, 0.40 vs. 1.32; 95% CI, 0.21 to 0.74 in SVS (+) vs. 95% CI, 0.51 to 3.35 in SVS (-);
for interaction=0.038).
As a first line strategy, SR achieved higher recanalization rates and a more favourable clinical outcome at 3 months compared to CA when MRI shows SVS within the thrombus.
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