Early-versus-Late Endovascular Stroke Treatment: Similar Frequencies of Nonrevascularization and Postprocedural Cerebrovascular Complications in a Large Single-Center Cohort Study

BACKGROUND AND PURPOSE

Endovascular treatment of acute ischemic stroke is now performed more frequently in the late window in radiologically selected patients. However, little is known about whether the frequency and clinical impact of incomplete recanalization and postprocedural cerebrovascular complications differ between early and late windows in the real world.

MATERIALS AND METHODS

We retrospectively reviewed all patients with acute ischemic stroke receiving endovascular treatment within 24 hours from 2015 to 2019 and included in the Acute STroke Registry and Analysis of Lausanne. We compared rates of incomplete recanalization and postprocedural cerebrovascular complications (parenchymal hematoma, ischemic mass effect, and 24-hour re-occlusion) in the early (<6 hours) versus late window (6-24 hours, including patients with unknown onset) populations and correlated them with the 3-month clinical outcome.

RESULTS

Among 701 patients with acute ischemic stroke receiving endovascular treatment, 29.2% had late endovascular treatment. Overall, incomplete recanalization occurred in 56 patients (8%), and 126 patients (18%) had at least 1 postprocedural cerebrovascular complication. The frequency of incomplete recanalization was similar in early and late endovascular treatment (7.5% versus 9.3%, adjusted P =.66), as was the occurrence of any postprocedural cerebrovascular complication (16.9% versus 20.5%, adjusted P = .36). When analyzing single postprocedural cerebrovascular complications, rates of parenchymal hematoma and ischemic mass effect were similar (adjusted P = .71, adjusted P = .79, respectively), but 24-hour re-occlusion seemed somewhat more frequent in late endovascular treatment (4% versus 8.3%, unadjusted P = .02, adjusted P = .40). The adjusted 3-month clinical outcome in patients with incomplete recanalization or postprocedural cerebrovascular complications was comparable between early and late groups (adjusted P = .67, adjusted P = .23, respectively).

CONCLUSIONS

The frequency of incomplete recanalization and of cerebrovascular complications occurring after endovascular treatment is similar in early and well-selected late patients receiving endovascular treatment. Our results demonstrate the technical success and safety of endovascular treatment in well-selected late patients with acute ischemic stroke.

Outcomes with Endovascular Treatment of Patients with M2 Segment MCA Occlusion in the Late Time Window

BACKGROUND AND PURPOSE

Randomized trials in the late window have demonstrated the efficacy and safety of endovascular thrombectomy in large-vessel occlusions. Patients with M2-segment MCA occlusions were excluded from these trials. We compared outcomes with endovascular thrombectomy in patients with M2-versus-M1 occlusions presenting 6-24 hours after symptom onset.

MATERIALS AND METHODS

Analyses were on pooled data from studies enrolling patients with stroke treated with endovascular thrombectomy 6-24 hours after symptom onset. We compared 90-day functional independence (mRS ≤ 2), mortality, symptomatic intracranial hemorrhage, and successful reperfusion (expanded TICI = 2b-3) between patients with M2 and M1 occlusions. The benefit of successful reperfusion was then assessed among patients with M2 occlusion.

RESULTS

Of 461 patients, 367 (79.6%) had M1 occlusions and 94 (20.4%) had M2 occlusions. Patients with M2 occlusions were older and had lower median baseline NIHSS scores. Patients with M2 occlusion were more likely to achieve 90-day functional independence than those with M1 occlusion (adjusted OR = 2.13; 95% CI, 1.25-3.65). There were no significant differences in the proportion of successful reperfusion (82.9% versus 81.1%) or mortality (11.2% versus 17.2%). Symptomatic intracranial hemorrhage risk was lower in patients with M2-versus-M1 occlusions (4.3% versus 12.2%, P = .03). Successful reperfusion was independently associated with functional independence among patients with M2 occlusions (adjusted OR = 2.84; 95% CI, 1.11-7.29).

CONCLUSIONS

In the late time window, patients with M2 occlusions treated with endovascular thrombectomy achieved better clinical outcomes, similar reperfusion, and lower symptomatic intracranial hemorrhage rates compared with patients with M1 occlusion. These results support the safety and benefit of endovascular thrombectomy in patients with M2 occlusions in the late window.

Predictors of Endovascular Treatment Procedural Complications in Acute Ischemic Stroke: A Single-Center Cohort Study

BACKGROUND AND PURPOSE

Procedural complications occur in 4%-29% of endovascular treatments in acute ischemic stroke. However, little is known about their predictors and clinical impact in the real world. We aimed to investigate the frequency and clinical impact of procedural complications of endovascular treatment and identify associated risk factors.

MATERIALS AND METHODS

From 2015-2019, we retrospectively reviewed all patients with acute ischemic stroke receiving endovascular treatment within 24 hours included in the Acute STroke Registry and Analysis of Lausanne. We identified patients having an endovascular treatment procedural complication (local access complication, arterial perforation, dissection or vasospasm, and embolization in a previously nonischemic territory) and performed logistic regression analyses to identify associated predictors. We also correlated procedural complications with long-term clinical outcome.

RESULTS

Of the 684 consecutive patients receiving endovascular treatment, 113 (16.5%) had at least 1 procedural complication. The most powerful predictors were groin puncture off-hours (OR = 2.24), treatment of 2 arterial sites (OR = 2.71), and active smoking (OR = 1.93). Patients with a complication had a significantly less favorable short-term clinical outcome (Δ-NIHSS score of -2.2 versus -4.33, P-value adjusted < .001), but a similar long-term clinical outcome (mRS at 3 months = 3 versus 2, P-value adjusted = .272).

CONCLUSIONS

Procedural complications are quite common in endovascular treatment and lead to a less favorable short-term but similar long-term outcome. Their association with treatment off-hours and at 2 arterial sites requires particular attention in these situations to optimize the overall benefit of endovascular treatment.

Correlation between ASPECTS and Core Volume on CT Perfusion: Impact of Time since Stroke Onset and Presence of Large-Vessel Occlusion

BACKGROUND AND PURPOSE

Both ASPECTS and core volume on CTP are used to estimate infarct volume in acute ischemic stroke. To evaluate the potential role of ASPECTS for acute endovascular treatment decisions, we studied the correlation between ASPECTS and CTP core, depending on the timing and the presence of large-vessel occlusion.

MATERIALS AND METHODS

We retrospectively reviewed all MCA acute ischemic strokes with standardized reconstructions of CTP maps entered in the Acute STroke Registry and Analysis of Lausanne (ASTRAL) registry. Correlation between ASPECTS and CTP core was determined for early (<6 hours) versus late (6-24 hours) times from stroke onset and in the presence versus absence of large-vessel occlusion. We used correlation coefficients and adjusted multiple linear regression models.

RESULTS

We included 1046 patients with a median age of 71.4 years (interquartile range, IQR = 59.8-79.4 years), an NIHSS score of 12 (IQR, 6-18), an ASPECTS of 9 (IQR, 7-10), and a CTP core of 13.6 mL (IQR, 0.6-52.8 mL). The overall correlation between ASPECTS and CTP core was moderate (ρ = -0.49, P < .01) but significantly stronger in the late-versus-early window (ρ = -0.56 and ρ = -0.48, respectively; P = .05) and in the presence versus absence of large-vessel occlusion (ρ = -0.40 and ρ = -0.20, respectively; P < .01). In the regression model, the independent association between ASPECTS and CTP core was confirmed and was twice as strong in late-arriving patients with large-vessel occlusion (β = -0.21 per 10 mL; 95% CI, -0.27 to -0.15; P < .01) than in the overall population (β = -0.10; 95% CI, -0.14 to -0.07; P < .01).

CONCLUSIONS

In a large cohort of patients with acute ischemic stroke, we found a moderate correlation between ASPECTS and CTP core. However, this was stronger in patients with large-vessel occlusion and longer delay from stroke onset. Our results could support the use of ASPECTS as a surrogate marker of CTP core in late-arriving patients with acute ischemic stroke with large-vessel occlusion.

Stroke chameleons: acute central pain mimicking acute coronary syndrome

BACKGROUND AND PURPOSE

'Stroke chameleons' refer to a group of syndromes that initially are not diagnosed as cerebrovascular events but are then found to represent stroke. The objective of this study was to report on acute ischaemic stroke (AIS) patients with chest or epigastric pain of central origin, clinically resembling an acute coronary syndrome (ACS).

METHODS

A prospective list was kept of AIS patients admitted to our institution between 2002 and 2014 with stroke symptoms appearing as an ACS on first clinical evaluation. For each identified patient, clinical and radiological features, delay to correct diagnosis, stroke etiology and 3-month functional outcome were reviewed. Data were mainly extracted from the Acute Stroke Registry and Analysis of Lausanne (ASTRAL).

RESULTS

Five AIS patients presenting mainly with chest or epigastric pain leading to a wrong diagnosis of ACS were identified. Cardiac evaluation showed minor electrocardiogram changes in two patients and isolated troponin elevation in one, subsequently shown to be of non-coronary origin. The correct diagnosis of AIS was made only between 1 h and 72 h after hospital arrival. Four patients presented a vertebrobasilar stroke. None of the patients received acute stroke revascularization therapy despite two of them being in the time window for such treatment.

CONCLUSION

Acute ischaemic stroke presentation can infrequently resemble an ACS. In cases of negative cardiac work-up, a central origin of chest pain should be considered, especially in the presence of subtle other neurological symptoms or signs. Appropriate diagnosis of stroke could avoid treatment delays and improve outcomes.

Predictors of progression in patients presenting with minor subcortical stroke

OBJECTIVES

Early neurological worsening is common in minor subcortical strokes (SS) and may lead to a poor outcome. We aimed to describe clinical and imaging features associated with progression.

MATERIAL AND METHODS

Consecutive patients with SS were divided into progressive and non-progressive. Progression was defined as an increase of NIHSS motor score ≥ 1 point within 72 h from onset. Vascular risk factors and imaging features (vascular territory, size and number of slices in which the lesion was visible, the presence of leukoaraiosis) were compared in the two groups. We investigated potential independent determinants of progression using stepwise logistic regression.

RESULTS

Thirty of 94 patients (31.9%) underwent progression. The distribution of vascular risk factors did not differ significantly between the two groups. Increasing number of risk factors was associated with a higher risk of progression (OR 2.2; 95% CI 1.1-4.5). Patients who progressed were more likely to have a lesion ≥ 15 mm in diameter (P = 0.004) or a lesion visible ≥ 3 slices (P = 0.007). After logistic regression stepwise adjustment for all the considered potential determinants, diameter ≥ 15 mm and severe leukoaraiosis proved to be independently associated with neurological worsening (OR = 6.3, 95% CI 2.0-19.6 and OR = 5.9, 95% CI 1.3-25.7, respectively).

CONCLUSION

In a series of consecutive SS, early neurological worsening was associated with a high vascular risk profile, a larger infarct size and the presence of severe leukoaraiosis. Based on the knowledge that extensive microvascular changes are a feature of severe leukoaraiosis, we hypothesize that stroke progression could be promoted through an impaired compensatory flow in the penumbral area.

[Prognosis of stroke patients undergoing intubation and mechanical ventilation]

BACKGROUND

To determine the outcome of patients with acute stroke requiring intubation and mechanical ventilation.

METHODS

DESIGN

review of the medical records of 33 patients with stroke intubated at presentation in hospital and not requiring neurosurgery or angiography.

SETTING

intensive care unit (ICU) of a non teaching hospital.

INTERVENTIONS

none.

MEASUREMENTS

the mean age (SD) was 73.3 (7.7), min 46 max 87, 18 males and 15 females, mean Glasgow coma scale (GCS) (min-max) was 4.5 (3-8).

RESULTS

The hospital mortality of intubated patients was 78.7% (26/33), mortality in the ICU was 69.69% (23/33). In survivors: infarction/hemorrhage (INF/HEM) were 4/3, mean age (SD) 75.2 (5.6), males/females 4/3, mean GCS (min-max) 5.2 (3-7), days in the ICU mean (DS) 18 (20.2). In patients who died: INF/HEM were 10/16, mean age (SD) 72.8 (8.2), males/females 14/12, mean GCS (min-max) 4.3 (3-8), days in the ICU mean (DS) 5.5 (8). The difference between groups was significant (p < 0.05) only for ICU staying. The evolution to brain death was observed in 10 cases (30.3%).

CONCLUSIONS

The overall prognosis of patients with acute stroke intubated and ventilated at presentation in hospital for deterioration is severe but the observed survival rate is sufficient to justify this treatment even in cases not requiring other invasive procedures like neurosurgery or angiography. A significant fraction of stroke patients is part of the potential organ donors pull.

[Multiple organ failure syndrome in infection caused by ictero-hemorragic Leptospira. Description of a clinical case]

A 53 years old fisherman was admitted to General Intensive Care Unit in Arezzo with signs and symptoms of Weil disease. An early acute respiratory failure developed. Radiological and haemodynamic findings confirmed a diagnosis of ARDS. The patient developed a severe jaundice, acute renal failure and ARDS (MOF multiple organs failure). To support different failures of the organs, CMV (continuous mandatory ventilation: CPPV with PEEP max 10 cm H2; IRV max 2:1) and AMV (assisted mandatory ventilation: Pressure Support Ventilation), haemofiltration, haemoperfusion and plasmapheresis were simultaneously used, that got better and better renal and respiratory performances. Haemodynamic worsening by PEEP during extracorporeal treatment was overcome by PSV very useful new ventilatory procedure even during weaning period. The patient treated in such manner survived without important disabilities. This care confirms that ARDS (non cardiogenic edema) and MOF can develop during Icterohaemorrhagic Leptospirosis.