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Yamazaki N, Koga M, Doijiri R, Inoue M, Miwa K, Yoshimura S, Fukuda-Doi M, Aoki J, Asakura K, Sasaki M, Kitazono T, Kimura K, Minematsu K, Yamamoto H, Ihara M, Toyoda K. Magnetic Resonance Imaging-Guided Intravenous Thrombolysis in Cardioembolic Stroke Patients With Unknown Time of Onset - Subanalysis of the THAWS Randomized Control Trial. Circ J 2024; 88:382-387. [PMID: 38220173 DOI: 10.1253/circj.cj-23-0662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2024]
Abstract
BACKGROUND We investigated the clinical effect of intravenous thrombolysis using a magnetic resonance imaging (MRI)-guided approach in cardioembolic stroke (CE) patients with unknown time of onset.Methods and Results: This subanalysis of the THAWS trial assessed the efficacy and safety of alteplase 0.6 mg/kg in CE patients with unknown time of onset and showing diffusion-weighted imaging-fluid-attenuated inversion recovery mismatch. Patients were classified as CE and non-CE using the SSS-TOAST classification system during the acute period. The efficacy outcome was a modified Rankin Scale score of 0-1 at 90 days. In all, 126 patients from the THAWS trial were included in this study, of whom 45 (35.7%) were diagnosed with CE. In the CE group, a favorable outcome was numerically more frequent in the alteplase than control group (52% vs. 35%; adjusted odds ratio [aOR] 2.25; 95% confidence interval [CI] 0.50-9.99). However, in the non-CE group, favorable outcomes were comparable between the alteplase and control groups (44% vs. 55%, respectively; aOR 0.39; 95% CI 0.12-1.21). Treatment-by-cohort interaction for a favorable outcome was modestly significant between the CE and non-CE groups (P=0.069). In the CE group, no patients experienced symptomatic intracranial hemorrhage (ICH) or parenchymal hematoma Type II following thrombolysis. CONCLUSIONS When an MRI-guided approach is used, CE patients with unknown time of onset appear to be suitable candidates for thrombolysis.
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Affiliation(s)
- Naoya Yamazaki
- Department of Neurology, Iwate Prefectural Central Hospital
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | | | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
| | - Mayumi Fukuda-Doi
- Department of Data Science, National Cerebral and Cardiovascular Center
| | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | - Koko Asakura
- Department of Data Science, National Cerebral and Cardiovascular Center
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School
| | | | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center
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Wada S, Yoshimura S, Toyoda K, Nakai M, Sasahara Y, Miwa K, Koge J, Ishigami A, Shiozawa M, Ogasawara K, Kitazono T, Nogawa S, Iwanaga Y, Miyamoto Y, Minematsu K, Koga M. Characteristics and outcomes of unknown onset stroke: The Japan Stroke Data Bank. J Neurol Sci 2023; 453:120798. [PMID: 37729754 DOI: 10.1016/j.jns.2023.120798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 08/14/2023] [Accepted: 09/06/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Clinical outcomes of unknown onset stroke (UOS) are influenced by the enlargement of the therapeutic time window for reperfusion therapy. This study aimed to investigate and describe the characteristics and clinical outcomes of patients with UOS. METHODS Patients with acute ischemic stroke (AIS) who were admitted within 24 h of their last known well time, from January 2017 to December 2020, were included. Data were obtained from a long-lasting nationwide hospital-based multicenter prospective registry: the Japan Stroke Data Bank. The co-primary outcomes were the National Institutes of Stroke Scale (NIHSS) scores on admission and unfavorable outcomes at discharge, corresponding to modified Rankin Scale (mRS) scores of 3-6. RESULTS Overall, 26,976 patients with AIS were investigated. Patients with UOS (N = 5783, 78 ± 12 years of age) were older than patients with known onset stroke (KOS) (N = 21,193, 75 ± 13 years of age). Age, female sex, higher premorbid mRS scores, atrial fibrillation, and congestive heart failure were associated with UOS in multivariate analysis. UOS was associated with higher NIHSS scores (median = 8 [interquartile range [IQR]: 3-19] vs. 4 [1-10], adjusted incidence rate ratio = 1.37 [95% CI: 1.35-1.38]) and unfavorable outcomes (52.1 vs. 33.6%, adjusted odds ratio = 1.27 [1.14-1.40]). Intergroup differences in unfavorable outcomes were attenuated among females (1.12 [0.95-1.32] vs. males 1.38 [1.21-1.56], P = 0.040) and in the subgroup that received reperfusion therapy (1.10 [0.92-1.33] vs. those who did not receive therapy 1.23 [1.08-1.39], P = 0.012). CONCLUSIONS UOS was associated with unfavorable outcomes but to a lesser degree among females and patients receiving reperfusion therapy.
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Affiliation(s)
- Shinichi Wada
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Michikazu Nakai
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yusuke Sasahara
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Akiko Ishigami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University Hospital, Yahaba, Iwate, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shigeru Nogawa
- Department of Neurology, Tokai University Hachioji Hospital, Hachioji, Tokyo, Japan
| | - Yoshitaka Iwanaga
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yoshihiro Miyamoto
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | | | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Kim BJ, Zhu K, Qiu W, Singh N, McDonough R, Cimflova P, Bala F, Kim J, Kim YS, Bae HJ, Menon BK. Predicting DWI-FLAIR mismatch on NCCT: the role of artificial intelligence in hyperacute decision making. Front Neurol 2023; 14:1201223. [PMID: 37377859 PMCID: PMC10292650 DOI: 10.3389/fneur.2023.1201223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023] Open
Abstract
Background The presence of diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) mismatch was used to determine eligibility for intravenous thrombolysis in clinical trials. However, due to the restricted availability of MRI and the ambiguity of image assessment, it is not widely implemented in clinical practice. Methods A total of 222 acute ischemic stroke patients underwent non-contrast computed tomography (NCCT), DWI, and FLAIR within 1 h of one another. Human experts manually segmented ischemic lesions on DWI and FLAIR images and independently graded the presence of DWI-FLAIR mismatch. Deep learning (DL) models based on the nnU-net architecture were developed to predict ischemic lesions visible on DWI and FLAIR images using NCCT images. Inexperienced neurologists evaluated the DWI-FLAIR mismatch on NCCT images without and with the model's results. Results The mean age of included subjects was 71.8 ± 12.8 years, 123 (55%) were male, and the baseline NIHSS score was a median of 11 [IQR, 6-18]. All images were taken in the following order: NCCT - DWI - FLAIR, starting after a median of 139 [81-326] min after the time of the last known well. Intravenous thrombolysis was administered in 120 patients (54%) after NCCT. The DL model's prediction on NCCT images revealed a Dice coefficient and volume correlation of 39.1% and 0.76 for DWI lesions and 18.9% and 0.61 for FLAIR lesions. In the subgroup with 15 mL or greater lesion volume, the evaluation of DWI-FLAIR mismatch from NCCT by inexperienced neurologists improved in accuracy (from 0.537 to 0.610) and AUC-ROC (from 0.493 to 0.613). Conclusion The DWI-FLAIR mismatch may be reckoned using NCCT images through advanced artificial intelligence techniques.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
- Gyeonggi Regional Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Kairan Zhu
- College of Electronic Engineering, Xi’an Shiyou University, Xi’an, Shaanxi, China
| | - Wu Qiu
- School of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Nishita Singh
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Neurology Division, Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Rosalie McDonough
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
| | - Petra Cimflova
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czechia
| | - Fouzi Bala
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Jongwook Kim
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
| | - Yong Soo Kim
- Department of Neurology, Nowon Eulji Medical Center, Eulji University, Seoul, Republic of Korea
| | - Hee-Joon Bae
- Department of Neurology, Seoul National University Bundang Hospital, Seongnam-si, Republic of Korea
- Department of Neurology, College of Medicine, Seoul National University, Seoul, Republic of Korea
| | - Bijoy K. Menon
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Calgary, AB, Canada
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Wang Z, Ji K, Fang Q. Low-dose vs. standard-dose intravenous alteplase for acute ischemic stroke with unknown time of onset. Front Neurol 2023; 14:1165237. [PMID: 37188314 PMCID: PMC10175638 DOI: 10.3389/fneur.2023.1165237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/04/2023] [Indexed: 05/17/2023] Open
Abstract
Background Standard-dose intravenous alteplase for acute ischemic stroke (AIS) in the unknown or extended time window beyond 4.5 h after symptom onset is both effective and safe for certain patients who were selected based on multimodal neuroimaging. However, uncertainty exists regarding the potential benefit of using low-dose alteplase among the Asian population outside the 4.5-h time window. Methods Consecutive AIS patients who received intravenous alteplase between 4.5 and 9 h after symptom onset or with an unknown time of onset guided by multimodal computed tomography (CT) imaging were identified from our prospectively maintained database. The primary outcome was excellent functional recovery, defined as having a modified Rankin scale (mRS) score of 0-1 at 90 days. Secondary outcomes included functional independence (an mRS score of 0-2 at 90 days), early major neurologic improvement (ENI), early neurologic deterioration (END), any intracranial hemorrhage (ICH), symptomatic ICH (sICH), and 90-day mortality. Propensity score matching (PSM) and multivariable logistic regression models were used to adjust for confounding factors and compare the clinical outcomes between the low- and standard-dose groups. Results From June 2019 to June 2022, a total of 206 patients were included in the final analysis, of which 143 were treated with low-dose alteplase and 63 were treated with standard-dose alteplase. After accounting for confounding factors, we observed that there were no statistically significant differences between the standard- and low-dose groups with respect to excellent functional recovery [adjusted odds ratio = 1.22 (aOR), 95% confidence interval (CI): 0.62-2.39; adjusted rate difference (aRD) = 4.6%, and 95% CI: -11.2 to 20.3%]. Patients of both groups had similar rates of functional independence, ENI, END, any ICH, sICH, and 90-day mortality. In the subgroup analysis, patients aged ≥70 years were more likely to achieve excellent functional recovery when receiving standard-dose rather than low-dose alteplase. Conclusion The effectiveness of low-dose alteplase might be comparable to that of standard-dose alteplase in AIS patients aged <70 years with favorable perfusion-imaging profiles in the unknown or extended time window but not in those aged ≥70 years. Furthermore, low-dose alteplase did not significantly reduce the risk of sICH compared to standard-dose alteplase.
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Koga M, Inoue M, Miwa K, Yoshimura S, Fukuda-Doi M, Aoki J, Asakura K, Kanzawa T, Ohtaki M, Kamiyama K, Yakushiji Y, Igarashi S, Doijiri R, Ito Y, Takagi Y, Sasaki M, Kitazono T, Kimura K, Minematsu K, Yamamoto H, Toyoda K. Intravenous Alteplase at 0.6 mg/kg for Unknown Onset Stroke with Prior Antithrombotic Medication: THAWS Randomized Clinical Trial. J Atheroscler Thromb 2023; 30:15-22. [PMID: 35197420 PMCID: PMC9899700 DOI: 10.5551/jat.63337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
AIM This study aimed to assess the potential effect of prior antithrombotic medication for thrombolysis in an unknown onset stroke. METHODS This was a predefined sub-analysis of the THAWS trial. Stroke patients with a time last known well >4.5 h who had a DWI-fluid-attenuated inversion recovery mismatch were randomly assigned (1:1) to receive alteplase at 0.6 mg/kg (alteplase group) or standard medical treatment (control group). Patients were dichotomized by prior antithrombotic medication. RESULTS Of 126 patients (intention-to-treat population), 40 took antithrombotic medication (24 with antiplatelets alone, 13 with anticoagulants alone, and 3 with both), and the remaining 86 did not before stroke onset. Of these, 17 and 52 patients, respectively, received alteplase, and 23 and 34, respectively, had standard medical treatment. Antithrombotic therapy was initiated within 24 h after randomization less frequently in the alteplase group (12% vs. 86%, p<0.01). Both any intracranial hemorrhage within 22-36 h (26% vs. 14%) and a modified Rankin Scale score of 0-1 at 90 days (good outcome) (47% vs. 48%) were comparable between the two groups. A good outcome was more common in the alteplase group than in the control group in patients with prior antithrombotic medication [relative risk (RR) 2.25, 95% confidence interval (CI) 1.02-4.99], but it tended to be less common in the alteplase group in those without (RR 0.69, 95% CI 0.46-1.03) (p<0.01 for interaction). The frequency of any intracranial hemorrhage did not significantly differ between the two groups in any patients dichotomized by prior antithrombotic medication. CONCLUSION Alteplase appears more beneficial in patients with prior antithrombotic medication.
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Affiliation(s)
- Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Mayumi Fukuda-Doi
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junya Aoki
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Koko Asakura
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Takao Kanzawa
- Department of Stroke Medicine, Institute of Brain and Blood Vessels, Mihara Memorial Hospital, Isesaki, Japan
| | - Masafumi Ohtaki
- Department of Neurosurgery, Obihiro Kosei Hospital, Obihiro, Japan
| | - Kenji Kamiyama
- Department of Neurosurgery, Nakamura Memorial Hospital, Sapporo, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Japan,Department of Neurology, Kansai Medical University, Hirakata, Japana
| | - Shuichi Igarashi
- Department of Neurology, Niigata City General Hospital, Niigata, Japan
| | - Ryosuke Doijiri
- Department of Neurology, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Yasuhiro Ito
- Department of Neurology, TOYOTA Memorial Hospital, Toyota, Japan
| | - Yasushi Takagi
- Department of Neurosurgery, Tokushima University, Tokushima, Japan
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan
| | - Takanari Kitazono
- Department of Medicine and Clinical Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazuo Minematsu
- Headquarters of the Medical Corporation ISEIKAI, Osaka, Japan
| | - Haruko Yamamoto
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Left Atrial Volume Index as a Predictor for Large-Vessel Occlusion in Cardiogenic Cerebral Infarction: A Single-Center Cohort Study. World Neurosurg 2021; 159:e79-e83. [PMID: 34883273 DOI: 10.1016/j.wneu.2021.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/30/2021] [Accepted: 12/01/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The left atrial volume index (LAVI) is considered to be the most accurate index to estimate the size of the left atrium (LA). In this study, we investigated the relationship between LA size measured by LAVI and the occurrence of large-vessel occlusion (LVO) in patients with cardiogenic cerebral infarction (CCI). METHODS This retrospective single-center cohort study involved 118 patients with CCI within the internal carotid artery (ICA) or middle cerebral artery regions seen between January 2015 and July 2020. In all patients, the type of CCI was determined according to the Diffusion-Weighted Imaging-Alberta Stroke Program Early Computed Tomography Scores (TOAST) subtype diagnosis criteria. LVO was defined as positive when magnetic resonance imaging and computed tomography angiography showed ICA, M1, or M2 occlusion, with all others defined as non-LVO. Clinical characteristics, including LAVI, were evaluated in the records of several patients to investigate if they were risk factors for developing LVO. RESULTS Seventy patients (59%) were diagnosed as having LVO infarction (ICA occlusion, n = 19 [16%]; M1 occlusion, n = 26 [22%]; and M2 occlusion, n = 25 [21%]). Echocardiography showed no difference between LVO and non-LVO in terms of the ejection fraction (P = 0.64), LA dimension (P = 0.93), and LA volume (P = 0.06). However, LAVI significantly differed between the LVO and non-LVO groups (P = 0.02). Multivariate logistic regression analysis showed larger LAVI as a significant risk factor for LVO (P = 0.01). CONCLUSIONS Our findings suggest that a larger LAVI is a predictor of developing LVO in patients with CCI.
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Miwa K, Koga M, Inoue M, Yoshimura S, Sasaki M, Yakushiji Y, Fukuda-Doi M, Okada Y, Nakase T, Ihara M, Nagakane Y, Takizawa S, Asakura K, Aoki J, Kimura K, Yamamoto H, Toyoda K. Cerebral microbleeds development after stroke thrombolysis: A secondary analysis of the THAWS randomized clinical trial. Int J Stroke 2021; 17:628-636. [PMID: 34282985 DOI: 10.1177/17474930211035023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIM We determined to investigate the incidence and clinical impact of new cerebral microbleeds after intravenous thrombolysis in patients with acute stroke. METHODS The THAWS was a multicenter, randomized trial to study the efficacy and safety of intravenous thrombolysis with alteplase in patients with wake-up stroke or unknown onset stroke. Prescheduled T2*-weighted imaging assessed cerebral microbleeds at three time points: baseline, 22-36 h, and 7-14 days. Outcomes included new cerebral microbleeds development, modified Rankin Scale (mRS) ≥3 at 90 days, and change in the National Institutes of Health Stroke Scale (NIHSS) score from 24 h to 7 days. RESULTS Of all 131 patients randomized in the THAWS trial, 113 patients (mean 74.3 ± 12.6 years, 50 female, 62 allocated to intravenous thrombolysis) were available for analysis. Overall, 46 (41%) had baseline cerebral microbleeds (15 strictly lobar cerebral microbleeds, 14 mixed cerebral microbleeds, and 17 deep cerebral microbleeds). New cerebral microbleeds only emerged in the intravenous thrombolysis group (seven patients, 11%) within a median of 28.3 h, and did not additionally increase within a median of 7.35 days. In adjusted models, number of cerebral microbleeds (relative risk (RR) 1.30, 95% confidence interval (CI): 1.17-1.44), mixed distribution (RR 19.2, 95% CI: 3.94-93.7), and cerebral microbleeds burden ≥5 (RR 44.9, 95% CI: 5.78-349.8) were associated with new cerebral microbleeds. New cerebral microbleeds were associated with an increase in NIHSS score (p = 0.023). Treatment with alteplase in patients with baseline ≥5 cerebral microbleeds resulted in a numerical shift toward worse outcomes on ordinal mRS (median [IQR]; 4 [3-4] vs. 0 [0-3]), compared with those with <5 cerebral microbleeds (common odds ratio 17.1, 95% CI: 0.76-382.8). The association of baseline ≥5 cerebral microbleeds with ordinal mRS score differed according to the treatment group (p interaction = 0.042). CONCLUSION New cerebral microbleeds developed within 36 h in 11% of the patients after intravenous thrombolysis, and they were significantly associated with mixed-distribution and ≥5 cerebral microbleeds. New cerebral microbleeds development might impede neurological improvement. Furthermore, cerebral microbleeds burden might affect the effect of alteplase.
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Affiliation(s)
- Kaori Miwa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Sohei Yoshimura
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Yahaba, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Saga University Faculty of Medicine, Saga, Japan.,Department of Neurology, Kansai Medical University, Hirakata, Japan
| | - Mayumi Fukuda-Doi
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.,Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yasushi Okada
- Department of Cerebrovascular Medicine and Neurology, Cerebrovascular Center, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Taizen Nakase
- Department of Stroke Science, Research Institute for Brain and Blood Vessels, Akita, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Shunya Takizawa
- 0Division of Neurology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Koko Asakura
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Junya Aoki
- 1Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Haruko Yamamoto
- Center for Advancing Clinical and Translational Sciences, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan
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Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, Palaiodimou L, Spiliopoulos S, Polizogopoulou E, Mantatzis M, Finitsis S, Karapanayiotides T, Ellul J, Bakola E, Brountzos E, Mitsias P, Giannopoulos S, Tsivgoulis G. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord 2021; 14:17562864211021182. [PMID: 34122624 PMCID: PMC8175833 DOI: 10.1177/17562864211021182] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.
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Affiliation(s)
- Georgios Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Guy Raphaeli
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lina Palaiodimou
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Eftihia Polizogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Stephanos Finitsis
- Department of Interventional Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Faculty of Health Sciences, AHEPA University Hospital, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Eleni Bakola
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian, University of Athens, School of Medicine, “Attikon” University Hospital, Iras 39, Gerakas Attikis, Athens, 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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