Safety and outcomes of routine endovascular thrombectomy in large artery occlusion recorded in the SITS Register: An observational study

BACKGROUND AND OBJECTIVE

We aimed to evaluate the safety and outcomes of thrombectomy in anterior circulation acute ischaemic stroke recorded in the SITS-International Stroke Thrombectomy Register (SITS-ISTR) and compare them with pooled randomized controlled trials (RCTs) and two national registry studies.

METHODS

We identified centres recording ≥10 consecutive patients in the SITS-ISTR with at least 70% of available modified Rankin Scale (mRS) at 3 months during 2014-2019. We defined large artery occlusion as intracranial internal carotid artery, first and second segment of middle cerebral artery and first segment of anterior cerebral artery. Outcome measures were functional independence (mRS score 0-2) and death at 3 months and symptomatic intracranial haemorrhage (SICH) per modified SITS-MOST.

RESULTS

Results are presented in the following order: SITS-ISTR, RCTs, MR CLEAN Registry and German Stroke Registry (GSR). Median age was 73, 68, 71 and 75 years; baseline NIHSS score was 16, 17, 16 and 15; prior intravenous thrombolysis was 62%, 83%, 78% and 56%; onset to reperfusion time was 289, 285, 267 and 249 min; successful recanalization (mTICI score 2b or 3) was 86%, 71%, 59% and 83%; functional independence at 3 months was 45.5% (95% CI: 44-47), 46.0% (42-50), 38% (35-41) and 37% (35-41), respectively; death was 19.2% (19-21), 15.3% (12.7-18.4), 29.2% (27-32) and 28.6% (27-31); and SICH was 3.6% (3-4), 4.4% (3.0-6.4), 5.8% (4.7-7.1) and not available.

CONCLUSION

Thrombectomy in routine clinical use registered in the SITS-ISTR showed safety and outcomes comparable to RCTs, and better functional outcomes and lower mortality than previous national registry studies.

P1455Atrial fibrillation detection by integrated trans-telephonic ECG monitoring after cryptogenic stroke in the years 2016–2018 in the Czech and Slovak Republics

Background

Cryptogenic strokes can be estimated to ∼3500 patients in the Czech (CZ) and 2000 patients in Slovak (SK) republics. Systematic screening in these patients and methods of ECG monitoring are generally uneven across different hospitals and districts.

Purpose

Assessment of integrated screening for atrial fibrillation (AF) after cryptogenic stroke was launched in collaboration with Czech Society of Cardiology and stroke centers in the year 2016.

Methods

Patients with stroke of unknown source within the last 3 weeks, and without AF/atrial tachycardia (AT) detected during in-hospital ECG monitoring, were referred by stroke centers into integrated database of the MDT center, who subsequently contacted the patients and shipped the loop/continuous ECG recorder (Vitaphone, Faros, ECGPocket) with automatic data transmission over cell phone to them directly home or into aftercare unit. ECG monitoring was scheduled for 3 weeks, and the data were regularly edited and evaluated to inform the referring stroke centers in case of AF detection. Upon termination of ECG monitoring, the device was returned to the MDT center, and the final report was sent to the referring physician for eventual treatment decision.

Results

The project involved 36 stroke centers in the CZ and 11 centers in SK. A total of 3.120 patients (65±17 years, 46% females) were monitored for 21.6±5.3 days. AF was detected in 308 (9.9%) patients. Additional findings included: AV block II-III in 62 (2%), NSVT over 5 QRS complexes in 249 (8%), sinus pauses over 4 seconds in 17 (0.5%), and regular SVT over 5 minutes in 69 (2.2%) patients. Total monitoring costs amounted to 374 400 € (120 €/patient). In CZ, the counts of monitored patients in 2016, 2017, 2018 were 302, 754, and 1148, which accounted for ∼10%, 21%, and 32%, respectively, of eligible patients.

Conclusion

Systematic screening of patients after cryptogenic stroke with integrated ECG monitoring has become adopted within 3 years to cover 39% of eligible patients in CZ. Besides approximately 10% AF/AT detection, clinically significant arrhythmias were identified in another 13% of patients.

Intravenous thrombolysis for patients with in-hospital stroke onset: propensity-matched analysis from the Safe Implementation of Treatments in Stroke-East registry

BACKGROUND AND PURPOSE

Recent cross-sectional study data suggest that intravenous thrombolysis (IVT) in patients with in-hospital stroke (IHS) onset is associated with unfavorable functional outcomes at hospital discharge and in-hospital mortality compared to patients with out-of-hospital stroke (OHS) onset treated with IVT. We sought to compare outcomes between IVT-treated patients with IHS and OHS by analysing propensity-score-matched data from the Safe Implementation of Treatments in Stroke-East registry.

METHODS

We compared the following outcomes for all propensity-score-matched patients: (i) symptomatic intracranial hemorrhage defined with the safe implementation of thrombolysis in stroke-monitoring study criteria, (ii) favorable functional outcome defined as a modified Rankin Scale (mRS) score of 0-1 at 3 months, (iii) functional independence defined as an mRS score of 0-2 at 3 months and (iv) 3-month mortality.

RESULTS

Out of a total of 19 077 IVT-treated patients with acute ischaemic stroke, 196 patients with IHS were matched to 5124 patients with OHS, with no differences in all baseline characteristics (P > 0.1). Patients with IHS had longer door-to-needle [90 (interquartile range, IQR, 60-140) vs. 65 (IQR, 47-95) min, P < 0.001] and door-to-imaging [40 (IQR, 20-90) vs. 24 (IQR, 15-35) min, P < 0.001] times compared with patients with OHS. No differences were detected in the rates of symptomatic intracranial hemorrhage (1.6% vs. 1.9%, P = 0.756), favorable functional outcome (46.4% vs. 42.3%, P = 0.257), functional independence (60.7% vs. 60.0%, P = 0.447) and mortality (14.3% vs. 15.1%, P = 0.764). The distribution of 3-month mRS scores was similar in the two groups (P = 0.273).

CONCLUSIONS

Our findings underline the safety and efficacy of IVT for IHS. They also underscore the potential of reducing in-hospital delays for timely tissue plasminogen activator delivery in patients with IHS.

Intravenous thrombolysis in young stroke patients: results from the SITS-ISTR

OBJECTIVE

To assess safety and efficacy of thrombolysis in 18- to 50-year-old patients compared to those aged 51 to 80 years recorded in the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR).

METHODS

A total of 27,671 patients aged 18-80 years treated with IV alteplase within 4.5 hours of symptom onset were enrolled in SITS-ISTR between 2002 and 2010. Main outcome measures were symptomatic intracerebral hemorrhage (SICH; deterioration of ≥4 points on the NIH Stroke Scale [NIHSS] within 24 hours and type 2 parenchymal hematoma), mortality, and functional independence (modified Rankin Scale [mRS] 0-2) at 3 months.

RESULTS

In the 3,246 (11.7%) patients aged 18-50, SICH occurred in 0.6% vs 1.9% in those aged 51-80 (adjusted odds ratio [aOR] 0.53; 95% confidence interval [CI] 0.31-0.90, p = 0.02). Three-month mortality was 4.9% and 14.4%, respectively (aOR 0.49; 95% CI 0.40-0.60, p < 0.001) and functional independence was 72.1% vs 54.5%, respectively (aOR 1.61; 95% CI 1.43-1.80, p < 0.0001). In multivariable analysis in young patients, baseline systolic blood pressure (SBP) was the only independent factor associated with SICH (p = 0.04). Baseline NIHSS, baseline glucose, and signs of infarction in baseline imaging scan were associated with higher mortality and poorer functional outcome. Male gender, mRS before stroke, and atrial fibrillation (AF) were associated with higher mortality, and age, SBP, and previous stroke were associated with mRS.

CONCLUSIONS

Treatment with IV alteplase is safe in young ischemic stroke patients and they benefit more compared to older patients. We found several factors associated with SICH, mortality, and functional outcome. These can be used to help in the selection of young ischemic stroke patients for thrombolysis.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that younger patients (18-50 years) with ischemic stroke symptoms treated with IV alteplase have lower morbidity and mortality compared to older patients (51-80 years).

[Quadruparesis as a complication of acute pancreatitis--case report]

Pancreatic encephalopathy is a rare complication of acute pancreatitis. Clinical features include focal neurological signs and acute oncet of dementia. Clinical picture can fiuctuate over the time and depends on phase of this disease. The progression and the regression of encephalopathy with relapse and remission of acute pancreatitis has been often described.

Separation of Siamese twins in Bratislava

At the pediatric surgical clinic in Bratislava, in the year 2000, we successfully carried out the separation of Siamese twins, which we classified as "ischiopagus tetrapus"+. The pelvic ring, the gastrointestinal tract and the urogenital system were all malformed. There was a common terminal ileum and only a short segment of the large intestine with a blind end. This was a case of non-developed anal segment and rectum. Each of the twins had two kidneys and two commonly shared urinary bladders. There were two uteruses, which were both bicornuate in nature with a fallopian tube arising from each of the horns as well as an ovary. The orifices of both urinary bladders and those of the two uteruses joined into a common urogenital sinus. The external ostia of this sinus represented a bizarre fissure with a single skin fold similar to the labium majus, located dorsally at the point of fusion of the pelvic structures. The act of separation was performed in two stages. Separation of the gastrointestinal tract was urgent due to the severe ileus caused by aplasia of the anus and the rectum. This first stage procedure was performed on the third day of admission (24.2.2000) after the babies had spent a month in other health institutions. The definitive separation was carried out a month after the first procedure (28.3.2000) following the optimal stabilization of the functions of the gastrointestinal tract. The uropoietic and genital systems were separated. A new pelvic ring and a pelvic floor were formed. The anterior abdominal wall was reconstructed and plastic correction of the skin in the gluteal and perineal regions was performed. The colostomies are functioning well and the twins pass well-formed stools. Lucia has long dry intervals between mictions. Andrea has shorter dry intervals. The girls have recently celebrated their third birthday. Their mental development is excellent; they speak Slovak and Hungarian languages. They have a well-developed locomotive apparatus, without any movement impairments. (Tab. 1, Fig. 16, Ref. 10.)

A double-blind randomised placebo-controlled evaluation of three doses of botulinum toxin type A (Dysport) in the treatment of spastic equinovarus deformity after stroke

BACKGROUND/OBJECTIVES

Calf muscle hypertonicity following stroke may impair walking rehabilitation. The aim of this study was to assess botulinum toxin (Dysport) in post-stroke calf spasticity.

METHODS

A prospective, multicentre, double-blind, placebo-controlled, dose-ranging study was performed to evaluate dysport at 500, 1,000 or 1,500 units in 234 stroke patients. They were assessed at 4-week intervals over 12 weeks.

RESULTS

The primary outcome measure, 2-min walking distance and stepping rate increased significantly in each group (p < 0.05, paired test), but there was no significant difference between groups (including placebo). Following dysport treatment, there were small but significant (p = 0.0002-0.0188) improvements in calf spasticity, limb pain, and a reduction in the use of walking aids, compared to placebo. Investigators' and patients' assessments of overall benefit suggested an advantage for dysport over placebo, but this was not significant. Sixty-eight patients reported 130 adverse events, with similar numbers in each group. The few severe events recorded were not considered to be treatment-related.

CONCLUSION

Dysport resulted in a significant reduction in muscle tone, limb pain and dependence on walking aids. The greatest benefits were in patients receiving dysport 1,500 units, but 1,000 units also had significant effects. Dysport 500 units resulted in some improvements. Since few adverse events were reported, this therapy is considered safe and may be a useful treatment in post-stroke rehabilitation of the leg. Possible reasons why functional improvements in gait parameters were not observed are also discussed.

[Hernias in the abdominal wall]

The authors emphasize the relapse frequency of the front abdominal wall hernias. Umbilical hernias, epigastric hernias, hernias in postoperative scars, as well as diastases of m. rectus abdominis are still not appropriately evaluated problem in surgery. Numeral surgical methods and procedures provide evidence of this fact. In spite of this, the relapses are frequent. In order to prevent relapses of hernias and to support the firmness of the abdominal wall, the authors use the corium graft technique. This study provides the description of the graft preparation. This surgical method was used in 54 patients, in whom no recurrence was recorded within the period of 1-3 years after surgery. The authors consider this procedure as being useful and effective. The methodical procedure is simple and economically advantageous, as autografts are ideal from the biological point of view. (Tab. 1, Fig. 6, Ref. 10.)

[Relation between toxoplasmosis and orofacial clefts in children]

The authors performed a serological observation of toxoplasmosis by using the methods of IFT, CFT and ELISA in 118 mothers and their children with orofacial clefts. The results were compared with those gained in the control group of healthy mothers and their children. Titre means of toxoplasma antibodies in inflicted mothers and their children were higher than in the control group. The results were evaluated statistically. The authors assume that a certain proportion of orofacial clefts may be induced by toxoplasmosis. (Tab. 6, Ref. 13.).

[Prenatal virus infections and orofacial clefts]

A potential teratogenic activity of virus infections caused by the viruses of rubella, influenza, parotitis, hepatitis B, cytomegalovirus and the Epstein-Barr virus was investigated. Specific antibodies against these viruses were examined serologically in children with orofacial clefts and in their mothers and the results were compared with those obtained in control children and their mothers. Different micromethods were used in performing the examinations (ELISA, RIA, NIR, KFR, HIT). Evaluation of the results and their statistical processing supports the assumption that prenatal infection may have occurred in the series studied induced by the viruses of influenza, rubella, cytomegalovirus, and possibly also by the Epstein-Barr virus. No association with the viruses of parotitis and hepatitis B was established. (Tab. 5, Ref. 36.)

[Structural basis of the spleen in rats]

The basic function of the spleen in the rat, similarly as in man, is to cleanse the blood of damaged old particles of the body itself, but also of foreign particles. To fulfill this function, the spleen is equipped with the white and red pulp with a specific structure of blood circulation. In an open system of circulation, blood from the arterial terminals opens into the cords of the red pulp, where it is adequately processed. From the cords the blood gets through the walls of sinuses, acting as the last filtration barrier, into the lumen of sinuses and then into the venous circulation. Unlike the human spleen, this organ in the rat has a marked marginal sinus and channel systems bridging the marginal zone. The channels mediate the circulation of lymphocytes between the red white pulp.

[Morphology of the human rib perichondrium from the aspect of arthroplasty of the small joints of the hand]

The human rib perichondrium is a suitable material for reconstruction interventions on small joints of the hand. Optical and electron microscopy analysis of the human rib perichondrium has shown some features different from the similar perichondrium in rabbits. In its superficial layers there are apart from the vascularity also myelinized nerve fibres, fat-cells and heparinocytes. In the medium layer and in the inner layer of the perichondrium there are cells which by their characteristics correspond to fibrocytes. Among them are collagen fibrillae coated with materials which can be fixed by the ruthenium red. The inner layer cannot be exactly distinguished from the cartilage of the rib.

In situ characterization of cells in periapical granuloma by monoclonal antibodies

Monoclonal antibodies were used in histopathologic and immunohistologic studies of periapical granulomas. In cellular zones, plasma cells and lymphocytes predominated, with variable numbers of fibroblasts, macrophages, and polymorphonuclear leukocytes. Labeling with monoclonal antibodies disclosed relatively infrequent, usually scattered macrophages. Plasma cells were numerous and frequently clumped. The vast majority of lymphocytes were T cells, scattered individually or in small groups of three or four cells and dispersed throughout the granulomas without any topographic predilection, with prevalence of T-suppressor/cytotoxic cells over T-helper/inducer cells. Our findings of numerous plasma cells, which were in agreement with descriptions of numerous immunoglobulin-producing cells by other authors, imply the participation of antibody-mediated immune reactions in periapical granulomas. The presence of cell-mediated immunity, in spite of numerous T cells, could not be confirmed.

Human hyaline cartilage--biochemical and immunochemical study

Hyaline cartilage from the knee or rib of newborns was divided in neutral salts into a soluble and insoluble part. The insoluble part was treated with collagenase and was separated into 2 peaks by gel chromatography on Sephadex G-200. The 1st peak revealed a low concentration of proteins, no hydroxyproline, and very high levels or uronates. In the 2nd peak, very high values of hydroxyproline and very low values of uronate were found. Thus the 1st peak contained only proteoglycans and no collagen, while the entire collagen was found in the 2nd peak. The individual fractions were inoculated into rabbits to obtain antibodies. Compared to the fraction containing macromolecular proteoglycans, antisera proved remarkably suitable particularly for analysis of human spleen, yet also of other organs. These anti-cartilage antisera visualized primarily spongy structures of pericapillary sheaths and circumferential reticulum of the periarterial lymphatic sheaths, but to a lesser extent also other extracellular structures of the spleen and of other organs.

The adult human female urethra. Enzyme-histochemical study

In the female urethra, the activity and distribution of 15 enzymes was determined by using both conventional and special histochemical methods. The enzymatic equipment differed according to the type of epithelial lining whose variation is characteristic for the female urethra. In the stratified squamous epithelium of the urethra, alkaline phosphatase, beta-glucuronidase, acetyl-beta-D-glucosaminidase, thiamine pyrophosphatase, and glucose-6-phosphatase exhibited but minimal or no activity, yet the other 10 enzymes studied displayed activity particularly in basally situated cells. Nearer to the lumen of the urethra, the activity in the epithelium kept decreasing and was mostly absent in superficial and desquamated cells. In the pseudostratified columnar and in the transitional epithelium of the urethra, the majority of enzymes showed an evenly distributed activity at all epithelial levels. In the apical parts of the most superficially situated cells bounding the lumen of the urethra, a distinct narrow zone of higher activity was observed. It was seen not only on determining the majority of dehydrogenases but also on examining acid phosphatase and naphthyl esterase. The endocrine cells occurring in the uroepithelial lining of the female urethra displayed, yet always with the exception of squamous epithelium (Zaviacic et al. 1983), distinct activity of acid hydrolytic enzymes, and of the enzymes studied it was particularly acid phosphatase. The majority of the demonstrated enzymes, of the dehydrogenases priority, is to be given to succinate dehydrogenase, enabled to differentiate readily between the highly active striated muscle fibers located in the most peripheral parts of the excisions along the urethral circumference and the smooth musculature of the urethral wall with a lower or only minimal activity.

Anatomical pathways from the white to the red pulp in the human spleen

In the human spleen we failed to find marginal zone bridging channels which in rats and mice are said to serve as return routes for lymphocytes from the white into the red pulp. In human spleens, using anticartilaginous antisera which distinctly visualized extracellular structures, in some parts we found the periarterial lymphocyte sheath to be closely attached to the red pulp, so that lymphocytes and other material could pass from the white pulp directly into the red pulp and vice versa. The strips of reticular fibres that seemed to bridge the marginal zone between the follicles and the red pulp proved to be components of reticular structures around the arteries, passing from the periarterial lymphocyte sheath into the follicles or from the follicles through the marginal zone into the red pulp.

Outer mantle zone of the follicle in the human spleen

The follicular circumferential connective fibre reticulum, which is a continuation of the circumferencial reticulum (CR) of the periarterial lymphocyte sheaths, was visualized at the periphery of lymphoid follicles in the human spleen by means of anticartilaginous antiserum. If this CR is considered to be the borderline between the follicular and extrafollicular structures, then at the inner aspect of the CR and at the periphery of the fully developed follicle two mantle zones can be distinguished: an inner zone consisting of small lymphocytes, and an outer consisting of medium-sized lymphocytes. Both all groups are B-lymphocytes displaying positive surface IgM. The reticulum is the same in both mantle zones and it is completely different from the reticulum of the marginal zone. In some instances it is so sparse as to appear to be absent completely. The newly delimitated outer mantle zone also has a specific cellular composition differing from the marginal zone. Most importantly, it does not possess that mixture of lymphocytes and other blood cells which is considered to be the defining feature of the marginal zone. The characteristic cellular components of the outer mantle zone are the densely accumulated medium-sized lymphocytes, with other cells interspersed very sporadically.

[Kaposi's sarcoma (an electron microscope case study)]

Endothelial histogenesis of sarcoma Kaposi was referred to in a case of 36-year old man studied by electron microscopy. Characteristic features corresponding to the literature were found: Weibel-Palade bodies, a ferritin-like material, phagocytosed erythrocytes, nuclear bodies, microfilaments and microtubules. Myelinated and unmyelinated axons were considered as remnants of original nervous tissue destroyed by the tumour or as nerve fibres accompanying proliferated vascular structures.

Pericapillary spongy sheaths in the human spleen. An immunohistological study

Antisera to extracts of human hyaline cartilage allow distinct visualization of extracellular structures of adventitial sheaths around arterial capillaries in the red pulp and marginal zone in the human spleen. These pericapillary sheaths have a prominently spongy character indicating their essential filter function. In childhood they are most marked. In premature and stillborn infants they sometimes occupy whole stretches of pulp cords, whereas in old age they are frequently diminished to small formations lacking a distinctly spongy structure.

Immunofluorescence and enzyme cytochemical analysis of arterial terminals in the human spleen

The simultaneous application of immunofluorescent and enzyme cytochemical methods made it possible to analyze the components of the walls of the arterial branches and arterial capillaries, and particularly the spongy arterial terminals in the red pulp of human spleen. The endothelium was identified by alkaline phosphatase demonstration, the basement membranes (BM) by means of antisera to glomerular BM, the media by using the same antisera, and the adventitia by means by antisera to hyaline cartilage, which are presumed to react particularly with adventitial structures. In the spongy arterial terminals visualized by means of anti-hyaline-cartilage antisera, the endothelium and mostly also BM could be detected, yet the enzyme cytochemical reaction to acid phosphatase and alpha-naphthyl acetate esterase and the immunofluorescent reaction to lysozyme yielded negative reactions. The findings suggest that neither macrophages nor other cells containing the given enzymes in detectable form are accumulated in these structures.

The use of anti-cartilage antisera in the study of human spleen

Antisera against human hyaline cartilage, particularly antisera against collagenase-treated residue obtained after extraction of cartilage homogenate with 3.4 mol dm-3 NaCl and extraction with 0.05 mol dm-3 sodium citrate buffer at pH = 3.2, reacted with different fibrillary and membraneous structures of the human spleen. Very intensive immunofluorescence was observed in special spongiform structures at the end of the arterial system, referred to as spongy arterial terminals. Fibrillary and membraneous structures situated perivascularly, in lymphatic sheaths and the periphery of follicles displayed similar reactions. The discontinuous walls of sinuses and reticular fibrils in pulp cords reacted less intensively. The given antisera are used to advantage as immunohistologic reagents since they clearly visualize the basic structure, and particularly the spongy arterial terminals, otherwise inconspicuous. In the hyaline cartilage of the rib and knee, the cartilage channels yielded the most intensive reaction. Of the other organs studied the marked reaction in the mesangium of the renal glomerulus was the most remarkable.