Background: Timely and effective recanalization to salvage the penumbra is the main determinant of outcome in acute ischemic strokes. Randomized controlled trials on late window mechanical ...thrombectomy (MT) have proved its safety and efficacy upto 24 h after stroke onset. We looked at the impact of time to reperfusion on vessel recanalization rates and short-term outcome in patients undergoing MT for large vessel occlusion. Methods: The clinical, imaging, and outcome of all patients undergoing MT upto 24 h from last seen normal was extracted from a prospectively maintained ischemic stroke database from January 2012 till September 2019. Results: There were 145 patients with a mean (SD) age of 58.2 (±14) years. Of them, 28 had wake up/unknown time of onset stroke and 9 presented beyond >360 min. There were 23 vertebrobasilar strokes. Median National Institute of Health Stroke scale score (NIHSS) at admission was 16.4 (Inter quartile range (IQR) 12-21). CT-Alberta Stroke program early CT score (CT-ASPECTS) was excellent (8-10) in 39 (31.6%) and fair (5-7) in 77 (63.6%) patients in anterior circulation strokes. About 25% underwent bridging therapy. Recanalization rates did not differ between those presenting early (<6 h) versus wake up strokes and late presenting patients (81.79% vs 71.9%). Symptomatic Intracerebral hemorrhage (ICH) occurred in 5%. At 3 months, excellent outcome (modified rankin scale <2) was observed in 28.9%. While Admission NIHSS remained strong predictor of poor outcome at 3 months, delay in presentation did not impact MT outcome (37.5% vs 45.79% and P = 0.460). Conclusions: The recanalization rates were similar in patients irrespective of the time to reperfusion from stroke onset. The functional outcome was not inferior in late presenters selected by advanced imaging.
Introduction: Carotid endarterectomy (CEA) is the standard treatment for patients with symptomatic carotid stenosis. Data from low- and middle-income countries are sparse on CEA and its outcomes. We ...aimed to describe the profile of our patients and factors associated with periprocedural cerebral ischemic events in patients with symptomatic carotid stenosis who underwent CEA in our institute. Methods: Retrospective review of patients with symptomatic carotid stenosis (50–99%) who underwent CEA between January 2011 and December 2021 was done. Clinical and imaging parameters and their influence on periprocedural cerebral ischemic events were analyzed. Results: Of the 319 patients (77% males) with a mean age of 64 years (SD±8.6), 207 (65%) presented only after a stroke. Majority (85%) had high-grade stenosis (≥70%) of the symptomatic carotid. The mean time to CEA was 50 days (SD±36); however, only 26 patients (8.2%) underwent surgery within 2 weeks. Minor strokes and TIA occurred in 2.2%, while major strokes and death occurred in 4.1% patients. None of the clinical or imaging parameters predicted the periprocedural cerebral ischemic events. The presence of co-existing significant (≥50%) tandem intracranial atherosclerosis (n = 77, 24%) or contralateral occlusion (n = 24, 7.5%) did not influence the periprocedural stroke risk. Conclusion: There is a delay in patients undergoing CEA for symptomatic carotid stenosis. Majority have high-grade stenosis and present late only after a stroke reflecting a lack of awareness. CEA can be performed safely even in patients with significant intracranial tandem stenosis and contralateral carotid occlusion.
Elevated admission blood pressure (BP) and BP variability have been shown to be associated with poor outcomes in most studies, while few studies have not found such an association. We investigated ...the association of various BP parameters with 3-month functional outcomes, mortality, and symptomatic intracerebral hemorrhage (sICH) in patients with acute ischemic stroke (AIS) receiving intravenous thrombolysis (IVT).
Patients with AIS who received IVT between January 2012 and March 2020 were analyzed. Admission BP, 24 h mean BP, and BP variability were noted for all patients. Outcomes assessed were 3-month modified Rankin Scale (mRS), mortality, and sICH.
Of the 237 patients, 161 were males. The mean admission systolic BP (SBP), 24 h mean SBP, and BP variability were 158.1 mm Hg (SD 30.25), 138 mm Hg (SD 16.78), 19.42 (SD 12.79), respectively. At 3 months, 147 (62%) patients had a good outcome (mRS 0-2). Multivariate analysis showed prior stroke, NIHSS >15, mean SBP ≥160 mm Hg, and SBP variability >45 to be significant predictors of poor outcome (mRS > 2) at 3 months. Eleven patients (4.6%) developed sICH. Age more than 60 years, presence of atrial fibrillation, admission blood sugar ≥180 mg/Dl, and SBP variability >45 predicted sICH. None of the above factors were predictive of 3-month mortality.
An elevated mean SBP and greater SBP variability were predictive of poor functional outcomes, whereas a high SBP variability predicted sICH. Our study emphasizes the need for BP control and minimizing large fluctuations to achieve good poststroke outcomes.
•There is no correlation between thrombus histology and etiological stroke subtype.•The RBC rich clots had good recanalization rate.•Platelet rich clots needed less number of passes during mechanical ...thrombectomy.
There is conflicting data on whether clot retrieved from mechanical thrombectomy can predict stroke etiology or the success of recanalization. We aimed to analyse the relation between thrombus histology and stroke aetiology as well as recanalization.
Histopathological analysis of clots retrieved from patients with acute ischemic stroke and large vessel occlusion was done. Quantification of the amount of fibrin, red blood cells(RBC), platelets and white blood cells (WBC) in the clots were done. The clinical, imaging data and recanalization parameters were collected. The correlation between clot composition and stroke etiology as well as recanalization were analysed.
Of the 77 patients, the mean age was 58. 67 ± 12.96 years. The stroke etiology were cardioembolism 44(57.1 %), large artery atherosclerosis 13(16.8 %), other determined aetiology 4(5.1 %) and undetermined in 16(20.7 %) patients. There was no significant correlation between the proportions of RBC-rich, platelet-rich and fibrin-rich thrombi and the stroke etiology. The susceptibility vessel sign was associated with RBC-rich clot(92.3 % vs 7.7 %, p = .03). All RBC-rich clots(100 %) had good recanalization(p = .05). Platelet-rich clots needed less number of passes(64.7 % vs 35.3 %, p = .006) and reduced groin puncture to recanalization time(87.9 % vs 12.1 %, p = .033). WBC-rich clots required lesser number of passes(57.5 % vs 42.5 %, P = .044). In multivariate analysis, WBC-rich clots (OR 0.230, CI 0.07–0.78, p = .018) showed an independent association with reduced recanalization attempts, while platelet-rich clots showed reduced recanalization time(OR 0.09, CI 0.01–0.63, p = .016).
There was no correlation between thrombus histology and the etiological stroke subtype. However, clot composition predicted the degree of recanalization and number of passes.
Identification of computed tomography (CT) thrombus imaging characteristics can predict the degree of recanalization and outcome after endovascular thrombectomy (EVT) in patients with acute ischaemic ...stroke and large vessel occlusion.
We analyzed the thrombus imaging characteristics and procedural factors and correlated with the degree of recanalization and functional outcome after EVT.
We evaluated the thrombus imaging characteristics (hyperdense MCA sign, thrombus location, length and thrombus permeability) from thin slice CT and CT angiogram. In addition, groin to recanalization time, number of passes, and EVT technique were documented. The primary outcome was degree of recanalization (mTICI score) and secondary outcome was modified Rankin scale (mRS) at 3 months.
The mean age of 102 patients was 60.5±11.8 years. Patients with hyperdense MCA sign (90 % vs 75%, p=0.07) and permeable thrombus (86 % vs 70 %, p=0.09) had good recanalization (mTICI grade 2b,2c or 3). The requirement of <3 passes (90 % vs 62 %, p= 0.001) was associated with good recanalization. Multiple logistic regression analysis showed thrombus permeability (OR 5.9; 95% CI 1.3-26.6, p=0.02), use of stent retreiver alone (without aspiration) (OR 5.4; 95% CI 1.3-22.5, p=0.02) and a puncture to recanalization ≤60 minutes (OR 7.9; 95% CI 1.7-36.8; p=0.008) were associated with good recanalization. The requirement of ≥3 passes was associated with poor functional outcome (OR 3.4;95% CI 1.2-9.8; p=0.02).
Thrombus permeability was a predictor of successful recanalization after EVT. The requirement of three or more passes during EVT was associated with poor recanalization and poor functional outcome.
Development of pulmonary AV fistula (PAVF) after bidirectional glenn shunt (BDG) results in significant cyanosis, impaired exercise performance, and increased morbidity and mortality. We attempted to ...detect and quantify PAVF in post-BDG patients by saline contrast transesophageal echocardiography (TEE) and compare with pulmonary angiography and pulmonary vein oximetry. This was a prospective study done between 2017 and 2018. Twenty-five children who underwent BDG and planned for cardiac catheterization prior to Fontan completion were included in the study. All patients underwent pulmonary angiography, oximetry, and saline contrast TEE at the time of cardiac catheterization. Twenty-two patients had undergone unilateral BDG surgery and three were palliated by bilateral BDG. The mean oxygen saturation was 80 ± 5.2%. Thirteen patients (52%) had preserved antegrade pulmonary blood flow. Eighteen patients (72%) had PAVF by angiography and oximetry, while 19 (76%) had PAVF identified by contrast echocardiography. There was moderate correlation between the degree of pulmonary venous desaturation and grading of PAVF by contrast echocardiography. PAVF was predominantly located in the lower zones of the lungs. Higher grades of PAVF were not seen in patients with preserved antegrade flow after BDG. Angiographically detected PAVF showed a steady increase with increasing delay to cardiac catheterization from BDG. Significant reduction in systemic saturation was limited to advanced grades of PAVF in patients after BDG. Saline contrast TEE, pulmonary venous oximetry, and pulmonary angiography equally identified PAVF in patients after BDG. Prognostic utility of the same needs to be assessed by long-term follow-up of these subjects.
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