Clinical and Functional Outcomes of Patients Receiving Cerebral Reperfusion Therapy: A Stroke Databank Study in Brazil

Intraarterial Thrombolysis as an Adjunct to Thrombectomy in Acute Ischemic Stroke: Current Status and Future Prospects

BACKGROUND AND PURPOSE

Intraarterial thrombolysis (IAT) has been sporadically used as an adjunct to mechanical thrombectomy (MT) in acute ischemic stroke patients for nearly two decades to improve distal arterial and microvascular perfusion even in patients with near complete or complete recanalization.

METHODS

We provide an overall narrative review that includes a systematic review and meta-analysis of two randomized controlled trials (RCTs), Chemical Optimization of Cerebral Embolectomy and Endovascular Recanalization in Patients with Acute Posterior Circulation Arterial Occlusion, to identify current and future implications. Risk ratios (RRs) were calculated from RCTs using a fixed-effects model. We identified 10 ongoing or planned RCTs after a search on clinicaltrials.gov and other sources, of which eight are in China, one in Europe, and one in Australia.

RESULTS

A previous meta-analysis of 16 (predominantly observational) studies involving 7572 MT-treated patients had identified 14% higher odds of functional independence (modified Rankin scale [mRS] 0-2) at 90 days in patients treated with IAT. In the current analysis of 321 patients who underwent MT in RCTs, 165 were randomized to IAT and 156 were in the control group. The RR of achieving an mRS score of 0-1 at 90 days postrandomization was higher in patients treated with IAT compared with the control group (absolute increase of 12.87%, RR = 1.39, 95% confidence interval [CI] 1.04-1.86). The rate of symptomatic intracerebral hemorrhage (sICH) within 24 h was slightly higher (absolute increase of 1.64%, RR = 0.95, 95% CI 0.07-13.30) in patients treated with IAT. The ongoing RCTs have sample sizes ranging from 80 to 498 that can identify very large minimal clinically important differences (MCIDs) (13%-20% increase) in primary outcomes, but smaller MCIDs (<10%) that can still result in practice changes with interventions associated with low cost and complexity and are easy to implement, such as IAT, will not be identified.

CONCLUSIONS

Observational studies and recent RCTs suggest a potential benefit of IAT in improving functional outcomes among patients post-MT, although the potentially increased risk of sICH, inadequate sample sizes, and lack of data from the United States need to be considered. A large, definitive, and generalizable RCT is required to establish the therapeutic value and safety profile of IAT prior to widespread incorporation into routine practice.

Clinical Outcomes of Extracranial Carotid Artery-Related Stroke Eligible for Mechanical Reperfusion on Top of Per-Guidelines Thrombolytic Therapy: Analysis from a 6-Month Consecutive Patient Sample in 2 Centers

BACKGROUND Systemic intravenous thrombolysis and mechanical thrombectomy (MT) are guideline-recommended reperfusion therapies in large-vessel-occlusion ischemic stroke. However, for acute ischemic stroke of extracranial carotid artery origin (AIS-CA) there have been no specific trials, resulting in a data gap. MATERIAL AND METHODS We evaluated referral/treatment pathways, serial imaging, and neurologic 90-day outcomes in consecutive patients, presenting in a real-life series in 2 stroke centers over a period of 6 months, with AIS-CA eligible for emergency mechanical reperfusion (EMR) on top of thrombolysis as per guideline criteria. RESULTS Of 30 EMR-eligible patients (33.3% in-window for thrombolysis and thrombolysed, 73.3% male, age 39-87 years, median Alberta Stroke Program Early Computed Tomography Score (ASPECTS) 10, pre-stroke mRS 0-1 in all, tandem lesions 26.7%), 20 (66.7%) were EMR-referred (60% - endovascular, 6.7% - surgery referrals). Only 40% received EMR, nearly exclusively in stroke centers with carotid artery stenting (CAS) expertise (100% eligible patient acceptance rate, 100% treatment delivery involving CAS±MT with culprit lesion sequestration using micronet-covered stents). The emergency surgery rate was 0%. Baseline clinical and imaging characteristics did not differ between EMR-treated and EMR-untreated patients. Ninety-day neurologic status was profoundly better in EMR-treated patients: mRS 0-2 (91.7% vs 0%; P<0.001); mRS 3-5 (8.3% vs 88.9%; P<0.001), mRS 6 (0% vs 11.1%; P<0.001). CONCLUSIONS In a real-life AIS-CA setting, the referral rate of EMR-eligible patients for EMR was low, and the treatment rate was even lower. AIS-CA revascularization was delivered predominantly in stroke thrombectomy-capable cardioangiology centers, resulting in overwhelmingly superior patient outcome. Large vessel occlusion stroke referral and management pathways should involve centers with proximal-protected CAS expertise. AIS-CA, irrespective of any thrombolysis administration, is a hyperacute cerebral emergency and EMR-eligible patients should be immediately referred for mechanical reperfusion.

Association between malnutrition risk and hemorrhagic transformation in patients with acute ischemic stroke

Background and aims

Malnutrition is a prevalent problem occurring in different diseases. Hemorrhagic transformation (HT) is a severe complication of acute ischemic stroke (AIS). Few studies have evaluated the association between malnutrition risk and hemorrhagic transformation in patients with acute stroke. We aim to investigate the influence of malnutrition risk on the risk of hemorrhagic transformation in patients with AIS.

Methods

A total of 182 consecutive adults with HT and 182 age- and sex-matched patients with stroke were enrolled in this study. The controlling nutritional status (CONUT) score was calculated to evaluate the malnutrition risk. HT was detected by follow-up imaging assessment and was radiologically classified as hemorrhagic infarction type 1 or 2 or parenchymal hematoma type 1 or 2. Logistic regression models were conducted when participants were divided into different malnutrition risk groups according to the objective nutritional score to assess the risk for HT.

Results

The prevalence of moderate to severe malnutrition risk in patients with AIS was 12.5%, according to the CONUT score. Univariate analysis showed that the CONUT score is significantly higher in patients with HT than those without HT. After adjusting for potential covariables, the patients with mild risk and moderate to severe malnutrition risk were associated with a higher risk of HT compared to the patients in the normal nutritional status group [odds ratio, 3.180 (95% CI, 1.139–8.874), P = 0.027; odds ratio, 3.960 (95% CI, 1.015–15.453), P = 0.048, respectively].

Conclusion

Malnutrition risk, measured by CONUT score, was significantly associated with an increased risk of hemorrhagic transformation in patients with AIS.