Susceptibility vessel sign predicts poor clinical outcome for acute stroke patients untreated by thrombolysis

Early Recanalization Among Patients Undergoing Bridging Therapy With Tenecteplase or Alteplase

BACKGROUND

Intravenous thrombolysis (IVT) with alteplase or tenecteplase before mechanical thrombectomy is the recommended treatment for large-vessel occlusion acute ischemic stroke. There are divergent data on whether these agents differ in terms of early recanalization (ER) rates before mechanical thrombectomy, and little data on their potential differences stratified by ER predictors such as IVT to ER evaluation (IVT-to-EReval) time, occlusion site and thrombus length.

METHODS

We retrospectively compared the likelihood of ER after IVT with tenecteplase or alteplase in anterior circulation large-vessel occlusion acute ischemic stroke patients from the PREDICT-RECANAL (alteplase) and Tenecteplase Treatment in Ischemic Stroke (tenecteplase) French multicenter registries. ER was defined as a modified Thrombolysis in Cerebral Infarction score 2b-3 on the first angiographic run, or noninvasive vascular imaging in patients with early neurological improvement. Analyses were based on propensity score overlap weighting (leading to exact balance in patient history, stroke characteristics, and initial management between groups) and confirmed with adjusted logistic regression (sensitivity analysis). A stratified analysis based on pre-established ER predictors (IVT-to-EReval time, occlusion site, and thrombus length) was conducted.

RESULTS

Overall, 1865 patients were included. ER occurred in 156/787 (19.8%) and 199/1078 (18.5%) patients treated with tenecteplase or alteplase, respectively (odds ratio, 1.09 [95% CI, 0.83-1.44]; P=0.52). A differential effect of tenecteplase versus alteplase on the probability of ER according to thrombus length was observed (Pinteraction=0.003), with tenecteplase being associated with higher odds of ER in thrombi >10 mm (odds ratio, 2.43 [95% CI, 1.02-5.81]; P=0.04). There was no differential effect of tenecteplase versus alteplase on the likelihood of ER according to the IVT-to-EReval time (Pinteraction=0.40) or occlusion site (Pinteraction=0.80).

CONCLUSIONS

Both thrombolytics achieved ER in one-fifth of patients with large-vessel occlusion acute ischemic stroke without significant interaction with IVT-to-EReval time and occlusion site. Compared with alteplase, tenecteplase was associated with a 2-fold higher likelihood of ER in larger thrombi.

Factors That Influence Susceptibility Vessel Sign in Patients With Acute Stroke Referred for Mechanical Thrombectomy

Background and Purpose

The presence of a Susceptibility Vessel Sign (SVS) in the acute phase of proximal occlusion ischemic stroke indicates the presence of deoxyhemoglobin in the thrombus. Thrombi composition changes over time. The aim of this study was to investigate whether the absence of SVS is associated with a shorter symptom onset to imaging time.

Methods

We retrospectively analyzed all patients referred for mechanical thrombectomy at Besançon University Hospital between 1 January 2015 and 31 December 2020 for whom readable T2^*-weighted imaging was available. We compared patient characteristics according to the presence or absence of an SVS. We also studied the subgroup for whom the exact symptom onset time was known. We performed a univariate statistical analysis, then a multivariate analysis on the variables that were statistically significant in the univariate analysis.

Results

Of the 389 patients included, 309 (79.4%) were SVS+. We found no significant relationship between SVS– and the time between symptom onset and imaging in the whole cohort. In the multivariate analysis, SVS– was associated with anticoagulant treatment (p < 0.01), and SVS+ with age (p = 0.023) and carotid terminus occlusion (p = 0.042). In the known symptom onset subgroup, SVS– was significantly associated with a shorter symptom onset -imaging time (p < 0.001), and this was confirmed in the multivariate analysis (p = 0.011; OR 0.911; 95% CI [0.844; 0.972]).

Conclusion

In the acute phase of proximal occlusion ischemic stroke, absence of SVS was associated with a shorter symptom onset–imaging time for patients with a known symptom onset time.

Susceptibility-weighted imaging in post-treatment evaluation in the early stage in patients with acute ischemic stroke

Objective

This study aimed to investigate the association between abnormal signs on susceptibility-weighted imaging (SWI) and post-treatment outcome in the early stage in patients with acute ischemic stroke.

Methods

Thirty-seven patients with middle cerebral artery territory infarction were recruited. Baseline and 24-hour follow-up magnetic resonance imaging was performed. Pre- and 24-hour post-treatment clinical conditions were assessed with the National Institutes of Health Stroke Scale (NIHSS) score. Prominent vessel sign (PVS) on SWI and infarcted areas on diffusion-weighted imaging (DWI) were assessed using the Alberta Stroke Program Early CT (ASPECT) score system. Susceptibility vessel sign (SVS) was evaluated and recorded. The associations between image abnormalities and clinical scores were analyzed.

Results

PVS was found in 35 patients and SVS in seven patients. The extent of PVS was significantly correlated with the post-treatment DWI ASPECT score (r = 0.79), but not with the post-treatment NIHSS score or the post−pre NIHSS difference score. The presence of SVS was significantly correlated with the post-treatment NIHSS score (r = 0.41).

Conclusion

PVS might be a useful predictor of early imaging prognosis and infarct growth in patients with acute ischemic stroke. SVS is related to a poor early outcome and could be useful for assessing stroke.