Welcome to the WSC 2022 Interactive Program

Background and Aims

Acute internal carotid artery (ICA) stenosis/occlusion with tandem occlusion of middle cerebral artery (MCA) hampers distal access for mechanical thrombectomy (MT) demanding controversial decision for simultaneous ICA stenting. The purpose of this paper is to evaluate the safety of emergency ICA stenting in combination with MT for acute ischemic stroke with tandem occlusions.

Methods

Retrospective analysis of 5 patients in whom emergency ICA stenting with MT was done from October 2021 to March 2022. All the patients with acute ischemic stroke (AIS) within 24hours of last seen well were included. CT angiogram was done in all the patients. IV thrombolysis was done in 2 patients. Dual anti-platelets were given in all the patients.

Results

Successful revascularization (Thrombolysis in cerebral infarction scale [TICI] ≥2c) was achieved in 5(100%). Good outcome at discharge (mRS ≤2) was achieved in all 5(100%) patients. None of the patients had symptomatic intracranial hemorrhage (sICH). Asymptomatic hemorrhage was noted in the infarcted area in one patient. Four out of five patients (80%) were treated with MT first followed by ICA stenting. Balloon angioplasty was attempted in all the patients. Four patients had >90% ICA stenosis and one had complete occlusion.

Conclusions

Emergency carotid stenting appears to be safe in patients with hemodynamically significant stenosis/complete occlusion especially if it hampers the process of concomitant distal MT.

Background and Aims

Reperfusion therapy is the most effective treatment for acute ischemic stroke (AIS). We aimed to analyze the changes in reperfusion therapy in real-world practice over the past 10 years when the advances in techniques of endovascular therapy (EVT) and expansion of therapeutic time window have been established.

Methods

Using data from the Clinical Research Center for Stroke-Korea, a nationwide multicenter stroke register, we analyzed trends in intravenous thrombolysis (IVT) and EVT between 2011 and 2020. Time trends were assessed for rates of IVT, EVT, door to needle (DTN) time, and door to puncture (DTP) time. Trends were analyzed with adjusting for age, sex, initial stroke severity using generalized linear mixed model with random effect for center.

Results

Among 70,450 AIS patients enrolled 17 participating centers, patients receiving reperfusion therapy increased from 14.7% in 2011 to 17.5% in 2020 (P<0.001). During the study period, EVT rate almost doubled from 5.4% in 2011 to 10.6% in 2020. However, IVT rate increased from 12.9% in 2011 to 15.5% in 2014 and then decreased to 10.9% in 2020. Among IVT cases, the proportions of DTN time either ≤60 min or ≤45 min has not changed over time, whereas that of DTP time ≤60 min among EVT cases has increased.

Conclusions

In a large multicenter register, we observed a significant increase in the reperfusion therapy rate with a marked increase in EVT for the treatment of AIS over the past 10 years, but IVT rate showed a decreasing trend from the mid-2010s.

Background and Aims

This post-hoc analysis aimed to determine whether early intubation impacts the treatment effect of endovascular therapy (EVT) in the Basilar Artery International Cooperation Study (BASICS) trial.

Methods

BASICS was a multicenter, randomized, controlled trial that investigated the efficacy of EVT in patients with basilar artery occlusion (BAO). Multivariable logistic regression adjusted for age, baseline NIHSS, IV-tPA and time from estimated BAO to randomization was built to explore the association between early intubation within 24 hours from estimated onset of BAO and favourable functional outcome defined as modified Rankin Scale (mRS) score of 0-3 at 90 days.

Results

Overall, 264 patients were considered for this post-hoc analysis (EVT, n=138; medical therapy, n=126). More patients underwent early intubation in the EVT than in the medical therapy group (63% vs. 48%; p=0.017). Intubation emerged as negative predictor of favourable functional outcome in the EVT group (aOR 0.24, 95%CI 0.09-0.59; p=0.002), but not in the medical care group (aOR 0.48, 95%CI 1.16-1.45; p=0.193). Compared with medical therapy, EVT tended to be associated with an increase in the odds of 90-days favourable functional outcome in non-intubated patients (aOR 2.49, 95%CI 0.89-6.96; p=0.083), while no such signal was evident in intubated patients (aOR 1.27, 95%CI 0.55-2.94; p=0.58).

Conclusions

Our post-hoc results of the BASIC trial raise the question whether early intubation contributes to worse functional outcome in BAO patients treated with EVT.

Background and Aims

Intravenous thrombolysis (IVT) is the standard therapeutic procedure for acute ischemic stroke (AIS). In early recurrence of an AIS, the administration of repeated IVT is controversial (risk of hemorrhagic complications). Due to the location of ischemia and predicted prognosis, we consider a prolonged low dose of IVT in some cases. The aim of the case report is to present a specific situation suitable for this therapy.

Methods

A patient (male, 67 years old) was brought in by the ambulance service for severe right lower limb paresis. CT were performed followed by standard IVT with clinical improvement. MR examination of the brain showed acute ischemia in the center of the semiovale left . At 25 hours after completion of IVT, the condition worsened sharply (plegia of the right upper limb and paresis of the right lower limb). CT didnt show a new abnormality. With regard to the localization of ischemia, we proceed to the administration of prolonged (10 hours) low-dose (20 mg rTPA) IVT.

Results

In the patient, the chosen therapy led to a significant improvement in the clinical condition (light right lateralization). No haemorrhagic complication was present.

Conclusions

According to case reports and publications of small cohorts of patients, prolonged low-dose IVT seems to be a relatively safe treatment for AIS, which we approach in very severe neurological deficits with a relatively favorable radiological finding - the extent of small ischemia in clinically important areas ,with lower potential for hemorrhagic complications.

Background and Aims

Outcome of thrombolysis in acute ischemic stroke with standard dose of alteplase (rtPA) and low dose alteplase (rtPA).

Methods

A total of 60 acute ischemic stroke patients reporting within 4.5 hours of onset of symptoms were enrolled from August, 2019 to June, 2021. Patients were evaluated, urgent NCCT head was performed, NIHSS and MRS score was calculated. Patients fulfilling AHA/ASA guidelines (2019 update) for thrombolysis were randomly assigned to receive low dose (0.6mg/kg;15% as bolus and 85% as infusion over one hour) or standard dose (0.9mg/kg;10% as bolus and 90% as infusion over one hour) alteplase with a maximal dose limit of 90mg. After thrombolysis, all patients were monitored in Intensive care unit at least for 24 hours and blood pressure was strictly monitored as per AHA/ASA guideline.

Results

According to TOAST classification most patients were large artery stroke followed by small vessel disease, cardioembolic, undetermined etiology and other determined etiology. Mean NIHSS and MRS of study patients were 12.72 (SD=4.95) and 4.19 (SD=0.89). Functional outcome of 0-2 (independent) on MRS scale was achieved by 58.33% patients in standard dose group and 54.17% in low dose group at 3 months.

Conclusions

Lower dose of alteplase was found to be non-inferior to standard dose of alteplase in terms of efficacy for thrombolysis in acute ischemic stroke. Symptomatic ICH is more common in thrombolysis with standard dose of alteplase and significantly less with low dose of alteplase.

Background and Aims

Several mimics of acute ischemic stroke may complicate thrombolysis. Developmental venous anomalies (DVA) are fairly common variants of normal cerebral vasculature. We report a case of a DVA presenting with acute focal neurologic deficits, resulting in a dilemma regarding stroke thrombolysis.

Methods

Case record and imaging findings of a patient with DVA who presented with acute focal neurologic deficits are reviewed and presented.

Results

A 25-year-old woman presented with a history of sudden left sided weakness and altered speech of 3 hours’ duration. She was alert, with mild dysarthria, left facial palsy, left upper limb weakness of grade 4/5 and hypoesthesia. NIHSS was 6. Plain CT at 3.5 hours after symptom onset showed a right frontal hypodensity and thrombolysis was considered.

However, thrombolysis was withheld on review of CT scan which showed a subtle hyperdensity in the right Sylvian fissure and predominently subcortical edema. A CT angiogram revealed an abnormal dilated vascular channel beginning at the tip of the right frontal horn and extending laterally and posteriorly to drain into the right transverse sinus. A DVA was diagnosed and thrombolysis deferred. Diagnosis was further confirmed by MRI and cerebral angiography. The patient received IV mannitol and rivaroxaban. She improved with no residual deficits.

Conclusions

Developmental venous anomaly should be considered in the differential diagnosis of acute ischemic stroke. CT brain demonstrating vascular channels inconsistent with normal arterial pattern or hemispheric hypodensity not confined to a vascular territory should be interrogated with additional imaging before thrombolysis.

Background and Aims

Eosinophils contribute to antibacterial defense, which are decreased in patients with acute ischemic stroke (AIS). However, the impact of eosinophils on stroke-associated pneumonia (SAP) remains unclear. Moreover, whether SAP is in the path of the association between eosinophils and clinical outcome also remains unclear.We aimed to assess the relationships between eosinophils, SAP, and clinical outcome after mechanical thrombectomy in patients with AIS.

Methods

A total of 328 consecutive patients with AIS who underwent mechanical thrombectomy were analyzed. Regression analysis was used to assess the effect of eosinophils on SAP, and its effect on poor outcome. Mediation analysis was utilized to assess the proportion of total effect by SAP on the association between eosinophils and poor outcome.

Results

Multivariater analysis revealed that eosinophils was independently associated with SAP after adjusting potential confounders (odds ratio, 0.00; 95% CI, 0.00–0.38; P = 0.0267), which is consistent with the result of eosinophils (dichotomous) as a categorical variable (odds ratio, 0.54; 95% CI, 0.31–0.96; P = 0.0342). A non-linear relationship was detected between eosinophils and SAP, whose inflection point was 0.06. Subgroup analyses further confirmed these associations. Eosinophils was also associated with poor outcome (odds ratio, 0.00; 95% CI, 0.00–0.14; P = 0.0124). And mediation analysis found that SAP partially mediated the negative relationship between eosinophils and poor outcome (indirect effect=-0.169; 95%CI: -0.339 – -0.040, P<0.001).

Conclusions

Lower eosinophil level was associated with higher SAP and poorer outcome, and SAP might play an important effect on the association between eosinophils and poor outcome.

Background and Aims

Early administration of intravenous recombinant tissue plasminogen activator, an essential treatment for patients with acute ischemic stroke improves patient outcomes. In 2016, the mean door-to-needle (DTN) time was 73 minutes during office hours for patients receiving intravenous thrombolysis, which was below MOH’s target of less than 60 minutes. The activation process was divided into 5 phases. Phase 4 (tele-stroke consultation) was the main contributing factor for the delay, which comprised of emergency doctors’ assessment using the National Institute of Health Stroke Scale (NIHSS), with an average time of 31 minutes exceeding the target of 15 minutes.

The aim is to reduce the average time in Phase 4 by 20% and shorten the mean DTN time from 73 minutes to less than 60 minutes by December 2019.

Methods

Three PDSA cycles were used for this quality improvement project from 2017 to 2019. In PDSA Cycle One and Two, the team established an office hour Case Manager-Led NIHSS assessment during stroke activation. In-house neurologist coverage was implemented in Cycle Three, replacing tele-stroke consult.

Results

Between 2016 and 2019, there was significant reduction in Phase 4 timing, from 31 minutes to 11 minutes which translated to a 65% reduction and an overall mean DTN time reduction from 73 minutes to 51 minutes (30% reduction).

In 2021, the team managed to sustain the interventions and achieved further mean DTN time reduction to 39 minutes.

Conclusions

With the continuous team effort in improving and sustaining the DTN time, the team managed to achieve clinical excellence in stroke care.

Background and Aims

The clinical benefit of thrombolysis in acute ischemic stroke is time dependent. Current guideline recommended door to needle whitin 60 minutes. In this study we examine the factors associated with delayed DTN times at National Brain Center Hospital Jakarta

Methods

The clinical benefit of thrombolysis in acute ischemic stroke is time dependent. Current guideline recommended door to needle whitin 60 minutes. In this study we examine the factors associated with delayed DTN times at National Brain Center Hospital Jakarta

Results

A total of 404 acute ischemic stroke in this study, Majority Age 40-59 years 143(50.18%), female 89 31.23%), Middle Education 98 (34.39%), Onset <3 hours 43 (15.09%),Moderate NIHSS 146 (51.23%), Office hour 119 (41,75%), and with pandemic status 178 (62.46%) in Delayed DTN. In final model, we found that four factor associated with delayed DTN include Age > 60 (OR=3.19 (1.11-9.15) p-values 0.03), Onset <3 hours (OR=4.81 (2.90-7.98) p-values 0.00), office hour (OR=0.56 (0.34-0.92) p-values 0.02), and pandemic status (OR=2.12 (1.21-3.68) p-values 0.00).

Conclusions

The most factors associated with delayed DTN include early onstet, older age, off hours admission, and pandemic status.

Background and Aims

Current evidence indicates that earlier administration of thrombolysis leads to better patient outcomes (Emberson et al., 2014) Hence the recommendation to achieve the door-to-needle time of less than 60 minutes.

Methods

Retrospective analysis of data collected from the National Stroke Audit (SSNAP). Patients received thrombolysis between 1st of January to 30th of June 2021 were identified and various phases of their initial assessments and treatments were analysed.

Results

Total of 34 patients received thrombolysis during this period with average DTN time of 63 minutes, only 10 patients were treated with DTN time below 60 minutes. Among the patients with DTN time over 60 minutes, 11 patients had long delays greater than 80 minutes. These 11 cases were patients who arrived hospital outside the normal working hours. Out of these, four cases were due to complex discussions with the Network consultants. Two cases had inadequate blood pressure control and two had delays completing CT. No reason was documented in the remaining 3 cases.

Conclusions

Results have shown that out of hours admissions are contributed to longer door-to-needle time in thrombolysis. These results highlight the importance of timely access to specialist input and on-call teams trained in acute stroke care to provide an efficient thrombolysis service. We recommend extended hours of local stroke specialist input and dedicated hotline /telemedicine service to improve the availability of network consultants when running the out of hours stroke service.

Background and Aims

We compared the thrombus removal capacity, potential complications, and extent of vessel wall damage of this novel device with those of the Solitaire FR device by performing a histopathologic analysis using an autopsied canine model. Through this experimental evaluation, we aimed to assess the safety and efficacy of the newly developed thrombus removal device.

Methods

Blood clots (autologous thrombus) were injected into 12 canines. Mechanical thrombectomy was performed in six canines using the newly developed Tromba thrombectomy device (experimental group) and in the other six canines using the Solitaire FR thrombectomy device (control group). Angiographic and histopathologic evaluations were performed on blood vessels subjected to mechanical thrombectomy.

Results

In the experimental group, the reperfusion patency was classified as “no narrowing” in five cases and “moderate narrowing” in one case. In the control group, the reperfusion patency was classified as “no narrowing” in four cases, “moderate narrowing” in one case, and “slight narrowing” in one case. In the experimental group, intimal proliferation was observed in only two cases, endothelial loss was observed in two cases, and device-induced medial injury was observed in one case. In the control group, intimal proliferation was observed in two cases, endothelial loss was observed in one case, and thrombosis (fibrin/platelet) was observed in one case.

Conclusions

The Tromba thrombectomy device showed no significant difference to the conventional Solitaire device in angiographic and histopathologic evaluations after thrombus removal. The stability and efficiency of the newly developed Tromba device are considered to be high and comparable to those of Solitaire.

Background and Aims

The efforts to increase the availability of thrombolytic therapy for ischemic stroke and to reduce the door to needle time may lead to increased frequency of Stroke mimic (SM) thrombolysis. The aim was to determine the frequency of thrombolysis in SM and to compare the frequency of SM thrombolysis in primary stroke center (PSC) vs Comprehensive stroke center (CSC).

Methods

Retrospective chart review of prospectively collected data (Quickr registry) of consecutive patients treated with intravenous thrombolysis for acute ischemic stroke in Alberta (Canada) from April 2016 to March 2021.

Results

Total of 2471 patients received thrombolysis during the study period. The Qucikr registry identified 169(6.83%) patients as SM, however on our review of record only 112(4.53%) were actual mimics. SM were younger with mean age of 61.66(±16.15) vs 71.08(±14.55) for stroke, SM was more frequent in females 52.67% vs 45.53% of stroke. Stroke severity measure by NIHSS was higher in stroke with median (IQR) of 10(5-17) vs 7(5-10) in SM. In SM, one patient (0.89 %) had minor intracranial hemorrhage, whereas in stroke, 341 (14.45%) had ICH, including 155 (6.57%) with parenchymal hemorrhage. There were no hospital mortality among patients of SM compared to 276(11.69%) stroke cases. The rate of thrombolysis in stroke mimics was higher in PSC 27(5.36%) vs 85 (4.3%) in CSC however, the difference is statistically not significant (P=0.6).

Conclusions

Our result confirms the safety and utility of tele-stroke in treatment of suspected stroke. Early thrombolysis of a suspected stroke has a larger benefit than delaying to confirm the diagnosis.

Background and Aims

‘Time is brain’. Worldwide, strategies are being developed to speed up the reperfusion time in patients of acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Here, we aimed to compare the workflow and outcomes of patients who underwent endovascular therapy (EVT) after being evaluated in mobile stroke unit (MSU)/stroke ambulance and shifted direct to angio-suite (DTA) vs who had a CT angiography (CTA) before shifting to angio-suite.

Methods

Retrospective chart review of prospectively collected data from November 2019 to June 2022, of the AIS patients evaluated in University of Alberta Hospital MSU.

Results

Total of 40 (8 DTA + 32 CTA) cases were included. Stroke severity measured by NIHSS was higher in DTA patients 21.5(14-24) vs 14.5(5-25) (p=0.003). The non-contrast CT head in MSU showed hyper dense vessel in 7(87.5%) DTA vs 11 (34.35%) in CTA (p=0.006).. The EVT timelines-median (IQR, 90th percentile) showed door to artery puncture time of 32.5 (23-50, 49.3) vs 79(39-264, 112.8), door to recanalization time 72.5(49-110, 96) vs 105.5(52-178,159.5), onset to recanalization time 212(140-276,270) vs 227 (148-442,335.5) in DTA vs CTA group respectively. The workflow times were significantly shorter in DTA group (p=0.0001). The mRS (0-2) at 3 months showed no significant difference between the groups, despite the fact that patients in DTA group had severe stroke at presentation.

Conclusions

Using MSU for direct angio tansfer in suspected LVO is an effective strategy to reduce the workflow time, the reduction in ischemic time will translate to a better to functional outcome.

Background and Aims

The efficacy of bridging ateplase prior thrombectomy in elderly patients and whether this procedure increases the risk of hemorrhagic transformation remains unclear.This study was conducted to analyze the efficacy of thrombolysis therapy for large-artery stroke in the elderly patients.

Methods

A prospective study of patients aged ≥ 80 with large artery acute ischemic stroke was performed at People’s Hospital 115, Ho Chi Minh City, Vietnam. We identified 68 patients treated with bridging with ateplase or direct thrombectomy during 1 year from October 2019 to December 2020. We evaluated mRS follow up at 90 days and intracranial hemorrhage rate between 2 groups. Good outcomes was defined as mRS ≤ 3 at 90 days.

Results

In total, 68 elderly patients were included: 21 (30.9%) received ateplase and thrombectomy and 57 (69.1%) received thrombectomy alone. Overall, no significant differences emerged comparing patients undergoing direct thrombectomy and bridging treatment for gender, hypertension, diabetes, NIHSS score. There were more severe intracerebral hemorrhage events ((PH2) – ECASS definition) within the bridging group compared with the other one (50.0% vs 6.25 %, p = 0.025). Compared to direct thrombectomy group, bridging group had lower likelihood of good outcomes at 90 days (19.0% vs 40.4%, p = 0.085), but there was no statistically significant difference between two groups. The mortality rate was similar between 2 groups (31.9% vs 38.1%, p = 0.619).

Conclusions

Direct thrombectomy maybe had similar efficacy to bridging in terms of the 90-day functional outcome in elderly patients, whereas bridging ateplase and mechanical thrombectomy increased risk of hemorrhagic transformation and procedure-related complications.

Background and Aims

Endovascular therapy (EVT) is highly recommended for acute anterior circulation large vessel occlusion (LVO) with the Alberta Stroke Program Early CT Score (ASPECTS) ≥6 due to occlusion of ICA or M1 MCA. However, the impact of EVT for patients who have an ischemic core with ASPECTS ≤ 5 (0–5) within 6 hours after onset was not well established. The aim of this study was to elucidate the outcomes of EVT for patients with a large ischemic core

Methods

This was a cross-sectional study. Patients with DWI-ASPECTS 0-5 caused by acute anterior LVO admitted to S.I.S Can Tho General Hospital within 6 hours after onset were enrolled. The primary outcome was defined as modified Rankin Scale (mRS) 0–3 at 90-day. Secondary outcomes were the mortality at 90-day. Safety outcomes were the cerebral edema, intracranial hemorrhage (ICH), decompressive craniectomy after EVT.

Results

A total of 43 patients were included. The mean of admission NIHSS (National Institutes of Health Stroke Scale) was 17.6. The number and percentage of patients with a mTICI reperfusion grade of 2b or higher was 41 (95.3%). The number and overall rates of patients with mRS 0 - 3 was 27 (62,8%). 90-days mortality rate was 16.3%. Functional independence occured in 16 (37,2%) patients. Cerebral edema and intracranial hemorrhage after EVT were observed in 22 (51,2%) and 11 (25,6%), respectively.

Conclusions

EVT may increase the likelihood of a favorable functional outcome in acute anterior LVO within 6 hours after onset. ICH should be considered when deciding treatment.

Background and Aims

A 27 year old lady presented to the emergency department with acute onset dense left sided weakness, left sided hemianopia and left sided facial droop. Her NIHSS score was 17. Her background was remarkable for steroid resistant idiopathic thrombocytopenic purpura (ITP)treated with Romiplostim and sirolimus.

Methods

A CT showed an established right middle cerebral artery (MCA) infarct and the CT angiogram confirmed an acute right MCA M1 occlusion. A perfusion study to identify if there was any salvageable brain was performed and this demonstrated a large penumbra despite a significant core volume infarct. Her platelet count was very low (13x109/L). Mechanical thrombectomy was undertaken with simultaneous administration of methylprednisolone, immunoglobulin and platelet infusion.

Results

Complete recanalisation (outcome TICI 3) was achieved in 20 minutes from groin puncture without complications. Stroke onset to arterial puncture interval was 3.5 hours. Strongly positive Ig-G anticardiolipin and beta-2 glycoprotein antibodies were found consistent with concomitant antiphospholipid syndrome. Post-operatively, she was able to mobilise independently with moderate left upper limb weakness. She was transferred to a stroke rehabilitation facility.

Conclusions

The thrombotic paradox of ITP is well known. Despite a number of ischemic stroke cases in the context of ITP, there is no consensus regarding therapeutic approach and no data regarding mechanical thrombectomy for similar cases. Our experience suggests that mechanical thrombectomy can be effective despite potential complications in thrombocytopenia.

Background and Aims

Intra-arterial thrombolysis with r-TPA is advised as per guidelines, however Intra-arterial Tenectaplase is still not utilised. This case report helps us to understand the utility of intra-arterial Tenectaplase in acute ischemic stroke due to large vessel occlusion.

Methods

A 63 Year old male presented to ER with acute onset right hemiplegia and aphasia of two hour onset. NIHSS was 12. His MRI brain showed left MCA territory infarct with Left MCA total occlusion. Patient was administered Inj Tenectaplase 16 mg IV bolus and taken up for Mechanical Thrombectomy. His initial cerebral DSA showed the left MCA was still occluded and there was 80% stenosis of left supraclinoid ICA. When the guiding catheter was advanced upto left ICA, subsequent left ICA angiography showed that left MCA had partially recanalised with residual thrombus and Right ACA was filling adequately. There was a financial constraint to perform mechanical thrombectomy hence a decision to perform Intra-arterial thrombolysis was taken.

Results

Microcatheter was advanced close to left MCA residual thrombus and 2 mg Tenectaplase was administered intra-arterial via microcatheter. Subsequent Left ICA angiography showed complete TICI3 recanalisation of left MCA, however Left ACA did not opacify. Hence Right ICA angiography was done which showed that Left ACA fills via Acomm artery.

Conclusions

EXTEND IA TNK trial has shown that Intravenous thrombolysis with tenectaplase results in 22% chance of recanalisation in large vessel occlusion. If Intra-arterial Tenectaplase can result in complete recanalistion in LVOs then it can be utilsed in resource limited settings where mechanical thrombectomy can be avoided.

Background and Aims

Asians who undergo intravenous thrombolysis have a greater risk of hemorrhagic transformation in acute ischemic stroke than western ethnicities. In this study, we explored the factors that are linked with hemorrhagic transformation (HT) after receiving intravenous thrombolysis in Indonesian population.

Methods

We performed a retrospective study including patients who received intravenous thrombolysis at National Brain Centre Hospital Prof. Dr. dr. Mahar Mardjono from June 2018 to July 2021. The associated factors for HT in patients after intravenous thrombolysis were determined using univariate and multivariate logistic regression in Stata V.16.0 software.

Results

The study involved 247 patients, with 28 patients (11.3%) in the HT group. We discovered a significant association between stroke severity (as measured by NIHSS score) (OR, 1.20 [95% CI, 1.02-1.19], p = 0.013) and hemorrhagic transformation after intravenous thrombolysis.

Conclusions

A high NIHSS score at admission was associated with hemorrhagic transformation after receiving intravenous thrombolysis. Therefore, we urge clinicians to be more cautious when doing intravenous thrombolysis in patients with severe stroke.

Background and Aims

Recently due to COVID-19, and vaccination for it, we were faced with more complex CVT cases where historical CVT management strategies were found to be ineffective in some patients. The success of endovascular treatments (EVT) for stroke arterial thrombus in the last decade and their recent enhanced availability twenty-four-seven allowed us to utilize the benefits of EVT in venous clots associated with CVT. Due to the rarity and equivocal results in some trials like TO-ACT (many of them seriously unwell at the time of EVT), the current practice is to wait for clinical and radiological deterioration to intervene with EVT. In our experience, we prefer not to wait for clinical deterioration but to intervene if there is evidence radiological worsening despite best medical treatment.

Methods

We describe three cases of CVT we managed in the last 12 months.. All three underwent EVT ,two clinically late and one early. All three patients were <50yrs and had no major co -morbidities.

Results

There was a clear difference in the clinical outcome based on the timing of the EVT. The patient with the early EVT intervention had a very good outcome while the other two cases, who had late EVT intervention had the worst outcome.

Conclusions

We propose that in patients diagnosed with CVT , EVT should proceed in a timely manner based on radiological worsening rather than clinical deterioration.

Background and Aims

We aim to compare the safety and effectiveness of intravenous thrombolysis (IVT) with recombinant tissue plasminogen activator in primary stroke centres (PSCs) equipped with neurologists versus acute stroke ready hospitals (ASRHs) without in-house neurologists.

Methods

We conducted a periodic cross-sectional study involving 5 PSCs and 7 ASRHs in Malaysia. Through review of medical records, real-world data was extracted for analysis. Consecutive adults with acute ischaemic stroke (AIS) who received IVT from 01 January 2014 to 30 June 2021 were included. Univariate and multivariate regression models were employed to evaluate the role of PSCs versus ASRHs in post-IVT outcomes and complications.

Results

A total of 313 multi-ethnic Asians, namely 231 (74%) from PSCs and 82 (26%) from ASRHs, were included. Both groups were matched in demographic, baseline clinical, and stroke characteristics. The efficiency of IVT delivery (door-to-needle time), post-IVT functional outcomes (mRS at 3 months post-IVT), and rates of adverse events (intracranial haemorrhages and mortality) following IVT were comparable between the 2 groups. Notably, 46.8% and 48.8% of patients in the PSCs and ASRHs group respectively (p=0.752) achieved favourable functional outcomes, namely mRS≤1 at 3 months post-IVT. Regression analyses demonstrated that post-IVT functional outcomes and adverse events were independent of the role of PSCs or ASRHs.

Conclusions

Our study provides real-world evidence which suggests that IVT can be equally safe, effective, and efficiently delivered in both PSCs and ASRHs. This may encourage the establishment of IVT service in more centres without neurologists, hence extending the benefits to a greater proportion of global stroke populations.

Background and Aims

Mechanical Thrombectomy (MT) is the treatment of choice in acute ischaemic stroke due to large vessel occlusion. Of the selection criteria for MT, an ASPECTS of 6 or more is required. However, there is some debate/studies proposing that MT can benefit patients with lower ASPECTS.

We present a case of a patient with ASPECTS=5, submitted to MT with excellent clinical outcome.

Methods

A 55-year-old female, with obesity and heavy smoking habits was brought to the emergency department with left hemiparesis with a duration of more then 12h and progressive worsening (admission NIHSS of 14). CT and Angio-CT showed an ASPECTS of 5 and an M1 occlusion of the right MCA. Perfusion study quantified a mismatch ratio and volume of 11.27 and 85.27ml, respectively. Patient was submitted to MT with first pass repermeabilization (TICI 3) using aspiration technique.

Results

After the procedure, the patient had major clinical improvement, with an NIHSS of 1 at discharge (at day 5 post MT), presenting only mild dysarthria. ECG revealed Atrial Fibrillation de novo and cardioembolic aetiology was proposed.

Conclusions

ASPECTS as a semi-quantitative grading system is a major tool in evaluating acute strokes in major vessel occlusion and selection for endovascular treatment. Although a simple, quick and reliable tool, it is limited and there is inter and intra-reader variability. CT perfusion better predicts the extend of brain tissue affected by ischaemia/infarct, particularly in cases of extended/undetermined duration. MT for strokes with ASPECTS lower than 6 should be considered with positive CT perfusion.

Background and Aims

We present a 73 year old lady with a history of hypertension and recent right hemi-arthroplasty, following traumatic neck of femur fracture. She was admitted with sudden onset dense right hemiplegia accompanied by right facial droop, dysarthria and hypoxia requiring oxygen.

Methods

Case Report

Results

Clinical picture was in keeping with left MCA territory ischaemic stroke. Initial CT Head was unremarkable. CT Angiography of carotids showed no large proximal vessel thrombus. However a large right pulmonary embolism (PE) was noted, which explained profound hypoxia suffered by the patient. Thrombolysis with Alteplase was performed with full neurological recovery. Post thrombolysis CT Head revealed acute left thalamic ischaemic infarct. Follow up CTPA study revealed near total resolution of PE.

Upon recovery on hyperacute stroke unit, the patient received treatment dose Tinzaparin for a week before therapeutic switch to Apixaban. Ultrasound Doppler examination demonstrated extensive right leg deep vein thrombosis encompassing the common femoral, femoral, popliteal and calf veins. Echocardiogram study showed preserved biventricular function with no evidence of right heart strain or pulmonary hypertension.

Patient made a full recovery with a good functional outcome.

Conclusions

This is an interesting case with a patient demonstrating two concomitant pathologies. Whilst the patient had PE, she didn’t meet criteria for thrombolysis. However, thrombolysis was offered for stroke using 63mg Alteplase as opposed to 100mg required for PE. Our case study supports the notion that patients with PE may be offered a lower dose in thrombolysis. More studies need to be conducted in order to corroborate this.

Background and Aims

Intravenous alteplase comprises the gold standard treatment for acute ischemic stroke (AIS), but can only be administered within 4.5 hours. In cases of wake-up stroke, a diffusion weighted imaging-fluid attenuated inversion recovery (DWI-FLAIR) mismatch has been correlated with onset below 4.5 hours. However, it is not infallible and may exclude potentially eligible patients who could benefit from thrombolysis. The authors report a case of wake-up AIS with DWI-FLAIR match that demonstrates clinical improvement following administration of low-dose alteplase.

Methods

A case report.

Results

A 45-year-old man presents with confusion and abnormal speech upon waking up 1 hour preceding admission. Previous history was significant for rheumatic heart disease. The neurological examination revealed isolated receptive aphasia. A head MRI was ordered, revealing an acute infarction of the M6 segment of the left middle cerebral artery (MCA) with a DWI-FLAIR match (Figure1). A diagnosis of mild disabling AIS (NIHSS 4) was made. Following a careful discussion and informed consent, low-dose intravenous alteplase was administered (0.6 mg/kg bodyweight), with no acute complications. A follow-up examination revealed improvement of aphasia with conversion to conduction aphasia (NIHSS 1). The patient was admitted to the stroke unit and referred for speech therapy.

Conclusions

Presence of a DWI-FLAIR match should not absolutely prevent potential candidates from receiving alteplase. The authors recommend that additional studies be done to evaluate the benefits of thrombolysis in select patients with DWI-FLAIR match, with the hopes of establishing an extended criteria for thrombolytic eligibility possibly taking into account the volume of infarct and severity of symptoms.

Background and Aims

Cancer can induce hypercoagulability, as well as the prevalence of active cancer in ischemic stroke patients, is around 5%. It has been found that the incidence of ischemic stroke in patients with active bladder cancer is 1.9 times higher compared to the general population, indicating that bladder cancer may be the etiology of ischemic stroke, which is called bladder cancer-related ischemic stroke (BCRIS).

Guidelines for treating cancer patients with IV-tPA are still unclear. The new American Heart Association/American Stroke Association guidelines state the high hemorrhage risk of IV-tPA treatment in patients with structural gastrointestinal malignancies and cancer patients post-treatment.

To present a rare case of stroke in an adult patient with known active bladder cancer and a nephrectomy performed in the past, intravenous thrombolysis was chosen as a therapeutic option.

Methods

We report a case of an 88-year-old patient with left-sided hemiparesis in a time window for intravenous thrombolysis (NIHSS 12). The patient has active bladder cancer and nephrectomy due to bladder cancer complications.

Results

There are no absolute contraindications for intravenous thrombolysis. The same was performed. The only complication that occurred after its completion was macroscopic hematuria. The patient was discharged with improvement (NIHSS 3).

Conclusions

The presence of active carcinoma is a risk factor for ischemic stroke, and various mechanisms for this relationship are possible. There are some controversies in the literature about treatment options in active carcinoma. We present this case to demonstrate the positive result of intravenous thrombolysis with neurological improvement and minimal complications in an adult patient.

Background and Aims

The purpose of the study is to understand elderlies and their carer’s decision-making process regarding large vessel obstruction via simulating the best-case and worst-case scenarios.

Methods

Patients over 65 years old and their carers were recruited and presented with a hypothetical scenario of a large vessel obstruction stroke during the interviews. The prognoses of different treatment approaches were explained with the best-case and worst-case scenarios that were based on patient’s health condition. They were then asked about their treatment decision (thrombectomy or medical treatment only) and what they considered an acceptable outcome with the modified Rankin scale (mRS).

Results

Amongst 14 respondents with a median baseline mRS of 2, only 50% of the patients would opt for thrombectomy. 44% of the carers would prefer endovascular interventions over medical therapies. Out of the 14 pairs of patients and carers, 5 carers (36%) would make a different treatment choice as their respective patients when acting as surrogate decision-makers if the patient is incapable of consent. Regarding treatment outcome, 86% of the patients considered an mRS of 3 to be an acceptable outcome for either treatment option. 55% of the carers also considered an mRS of 3 to be an acceptable outcome. Overall, 10 out of 14 pairs of patients and carers expressed the same treatment outcome score.

Conclusions

Notably, a substantial portion of patients and carers had divergent treatment choices regarding thrombectomy, highlighting the challenge in obtaining valid consent during the emergency setting of large vessel stroke.

Background and Aims

Traditional vascular access for endovascular thrombectomy (EVT) in large vessel occlusions (LVO) is through the femoral artery, but unfavorable anatomy can cause procedural difficulties necessitating alternative access. The Bovine/Aortic arch/Dolichoarteriopathy (BAD) score, based on computed tomography measurements of the aortic arch and carotid arteries, was previously described to quantify patients’ anatomical complexity. This study aimed to determine if BAD score is associated with reperfusion time, success rate, and outcome in LVO patients after EVT via the femoral approach.

Methods

Patients who received EVT for anterior circulation LVO between January 2018 and September 2021 were identified retrospectively. Data on the patients' premorbid status, occlusion site, BAD score, EVT procedural details, and outcomes up to 6 months postoperatively were extracted. Univariate and multivariate analyses were performed with SPSS Statistics v26.

Results

121 patients with anterior circulation LVO were included. Average time from groin puncture to first and final intra-arterial perfusion were 65.0 minutes (SD 48.5 minutes) and 73.1 minutes (SD 51.2 minutes) respectively. Higher BAD score was significantly correlated (p < 0.05) with older age, longer puncture to reperfusion time, lower procedural success, and worse 3-month functional outcome.

Conclusions

Higher BAD score is associated with more difficult anterior circulation EVT via the femoral artery and worse clinical recovery. Preoperative selection of patients with a high BAD score may be necessary to decide for direct vascular access through the carotid instead of the femoral artery, which would decrease reperfusion times and improve patient outcomes.

Background and Aims

The widely recommended standard dose of recombinant tissue plasminogen activator (r-tPA) is 0.9 mg/kg. But practically, not all patients are treated with the standard dose in the real world for various reasons. Whether the nonstandard dose coefficient (dose/weight) r-tPA can be equivalent to the standard dose is still under research.

Methods

Data were obtained from 537 patients who received r-tPA thrombolysis in Shanghai Sixth People’s Hospital stroke center in five years (2014-2019). We observed whether different dose groups [nonstandard dose group (0.6 mg/kg ≤ dose < 0.9mg/kg) and standard dose group (0.9 mg/kg)] were significantly correspondence to different outcomes [efficacy: 3 months mRS 0-1 (3m-mRS0-1); safety: symptomatic intracranial hemorrhage within 24 hours (24h-sICH) and 3 months mortality (3m-death)]. The effect of r-tPA dose coefficient on outcomes in different age subgroups and baseline NIHSS subgroups were also observed.

Results

There are 265 patients given standard dose treatment, and 272 given nonstandard dose. Baseline NIHSS before thrombolysis, admission glucose and systolic blood pressure (SBP) in general were significantly related to 3m-mRS0-1 and 3m-death, 24h-sICH. DNT significantly affected on the 3m-mRS0-1 (p =0.016) and 3m-death (p =0.003). History of atrial fibrillation significantly affected on 24h-sICH (p <0.001) and 3m-death (p=0.022). There was no significant difference between non-standard dose group and standard dose group in 3m-mRS0-1, 3m-death and 24h-sICH (p=0.567, 0.327, 0.415 respectively).The dose coefficient present a significant negative correlation (p=0.034, B=-4.290) with 3m-death in NIHSS <16 sub-group.

Conclusions

The non-standard dose group was as safe and effective as the standard dose group in our study.

Background and Aims

Red blood cell distribution width (RDW) and inflammatory biomarkers alone were associated with functional outcomes in acute ischemic stroke (AIS) patients. Here we aimed to investigate the combined effect of RDW and inflammatory biomarkers on in-hospital outcomes of AIS patients with thrombolysis.

Methods

A total of 417 consecutive AIS patients with thrombolysis were retrospectively included. The participants were divided into four groups according to the cut-off of RDW and inflammatory biomarkers [white blood cell (WBC) or C reactive protein(CRP)] identified by receiver operating characteristic (ROC) curve: LRLW(low RDW and low WBC), HRLW(high RDW and low WBC ), LRHW(low RDW and high WBC), and HRHW( high RDW and high WBC); or LRLC( low RDW and low CRP), HRLC( high RDW and low CRP), LRHC( low RDW and high CRP ), and HRHC( high RDW and high CRP), respectively.

Results

The risk of in-hospital pneumonia was significantly higher in HRHW and HRHC groups compared with that in LRLW and LRLC groups (OR 12.16, 6.93; P < 0.001) respectively. Patients in HRHW and HRHC groups were 9.31 or 3.38 fold more likely to have poor outcomes at discharge, compared with those in LRLW and LRLC groups(P <0.001). The C-statistics of the basic model and adding WBC and RDW, or CRP and RDW to the basic model for at discharge outcome and pneumonia were 0.859, 0.885 and 0.864; 0.874, 0.898 and 0.891, respectively.

Conclusions

The combination of RDW and inflammatory biomarkers within 4.5 hours since onset had a better predictive power for at-discharge functional outcome and pneumonia.

Background and Aims

In patients with strokes caused by large vessel occlusions, delays in door-to-groin puncture time (DGPT) are associated with worse clinical outcomes. Nottingham University Hospitals (NUH) provides the East Midlands’ Mechanical Thrombectomy (MT) service in the United Kingdom. We present results from a series of changes leading to the development of the NUH Comprehensive Stroke Centre (CSC) with a view to show improvement in DGPT and patient outcomes.

Methods

242 patients admitted from eight hospitals across the Trust’s referral network underwent MT between January 2019 and January 2022. The development of the NUH CSC included relocation of stroke services from Nottingham City Hospital to Queens’ Medical Centre (QMC), a major trauma centre where interventional services including MT and neurosurgery are based, as well as the integration of stroke assessment within the QMC Emergency Department pathways.

Results

Comparing the outcomes before (n=131) and after (n=111) our interventions in patients with a mean age of 69.9 and 70.2 years respectively demonstrated a reduction in DGPT time from 5.6 to 3.4 hours, improvement in the average modified Rankin Score on discharge from 3.71 to 3.67 and NIHSS improvement at 24 hours post-MT from 8.43 to 8.46.

Conclusions

Our interventions led to a reduction in DGPT time and better functional outcomes on discharge. A comparable NIHSS improvement may be due to an increase in the proportion of patients eligible for MT (e.g. change in selection criteria to beyond 6 hours after symptom onset). Further studies are required to establish the effects of our interventions in the long term.

Background and Aims

Background and aims: Previous studies stimulated debates on the use of a lower-dose rtPA for acute ischemic stroke (AIS) in Asian population. We aimed to explore the safety and efficacy of low-dose rtPA in Chinese patients using a real-world database.

Methods

Methods: We analyzed data from the Shanghai Stroke Service System. Patients receiving intravenous rtPA within 4.5 hours after symptom onset were included. These patients were divided into low-dose rtPA group (0.55–0.65 mg/kg) and standard-dose rtPA group (0.85–0.95 mg/kg). The primary outcome was rate of mortality and disability, defined as a score of 2 to 6 on the modified Rankin scale(mRS) at discharge. The secondary outcomes were in-hospital death, symptomatic intracranial hemorrhage(sICH), functional independence (mRS score 0-2) and the favorable outcome (mRS score 0-3).

Results

Results: From January 2019 to December 2020, a total of 1,423 patients were enrolled, 394(27.7%) were treated with low-dose intravenous rtPA. The median age of the patients was 71 years and 37.5% were women.The propensity score analysis showed that low-dose group had significantly higher rates of disability and death (OR=1.46, 95%CI[1.12,1.91], p=0.005) and less functional independence (OR=0.69, 95%CI[0.51,0.93],p=0.01) than the standard-dose group. After adjustment for the baseline variables, there were no significant differences in symptomatic intracranial hemorrhage, in-hospital death, or the favorable outcome between standard-dose and low-dose rtPA group.

Conclusions

Conclusions: Our study demonstrated that low-dose rt-PA may lead to a poor functional outcome without lowering the risk of SICH compared to standard-dose rtPA for AIS patients in China.

Background and Aims

Endovascular Treatment (EVT) is the gold-standard treatment for Acute Ischemic Stroke (AIS). Prior to December 2019, when patients with AIS arrived at CGH ED, ambulance would be called to standby for EVT transfer as CGH does not provide such service. However, not every standby resulted in patient transfer.

From Jan to Dec 2019, 159 ambulance standbys during office hours. A base charge of S$32.10 is applied for each standby. Out of 159 cases, 24 cases (15.1%) utilized the ambulance service. Low ambulance utilization rate resulted in cost wastage.

The aim of this project is to reduce unnecessary ambulance standbys and achieve cost saving by increasing ambulance service utilization rate from 15.1% to 80% by June 2021.

Methods

PDSA cycle was used for this quality improvement project. The work process was streamlined to standby ambulance when patient was potentially eligible for EVT transfer as compared to the initial blanket standby for AIS cases.

All data were extracted from Research Electronic Data Capture (REDCap) from January 2019 to June 2021. The outcome measures were ambulance utilization rate and cost saving for ambulance service.

Results

Ambulance utilization rate increased from 15.1% (Jan - Dec 2019) to 81.5% (Jan – Jun 2021) and prevented 292 unnecessary ambulance standbys from Jan 2020 to Jun 2021. This resulted in a cost saving of at least S$9373.20.

Conclusions

With the implementation of the new work process for ambulance standby, the ambulance utilization rate increased fivefold, resulting in cost-saving and resource optimization without compromising patients’ outcome.

Background and Aims

Acute Basilar artery occlusion (BAO) often confers a very poor prognosis despite recent advances in endovascular therapy (EVT). Recent randomised controlled trials failed to demonstrate a clear benefit of EVT in posterior circulation strokes. Less is known of the benefit and the rescue strategy of EVT for BAO in the presence of ICAD.

We aim to report a consecutive series of acute BAO due to ICAD-O presenting in Singapore General Hospital (SGH) in 2021, highlighting the clinical presentation, treatment approach and lessons learnt.

Methods

We included 4 consecutive patients with ICAD BAO who underwent mechanical thrombectomy in 2021 to form this case series. The data collected is based on clinical and imaging records review.

Results

The data are presented in the table below. Several observations were made:

1. Identification of BAO can be challenging due to the “atypical” presentation compared to anterior circulation infarct resulting in delayed diagnosis and treatment

2. Patients with concomitant medical condition or complication from ICU stay tend to have worse outcome despite successful re-canalisation.

3. Rescue therapy should be considered for ICAD BAO where perfusion to the basilar top is compromised by the proximal steno-occlusion and there are no collaterals from the posterior communicating artery.

*Atypical presentation, stroke code activated at 26 hours after admission.

**Discovery time.Transferred from primary stroke centre.

***Inpatient mortality.

PH2: Parenchymal Hemorrhage 2

DKA: Diabetic ketoacidosis

Conclusions

We share our single centre experience in treatment of 4 consecutive cases of ICAD BAO with regards to the treatment approach, observations and lessons learnt.

Background and Aims

Due to the development of endovascular devices and clinical experience, the recanalization rate after intraarterial thrombectomy (IA-Tx) has increased. However, in some patients, recanalization is not always beneficial for clinical outcomes. The purpose of this study is to determine which method, CT- or MR-based P/D-mismatch image evaluation, results in better clinical outcomes.

Methods

This study analyzed 143 patients with anterior circulation large vessel occlusion (LVO) treated by IA-Tx. In the MRI group (n = 80), an image was obtained after IV-tPA before the IA-Tx; in the CTP group (n = 63), a CTP image collected as an initial study was analyzed. In the CTP group, the authors analyzed P/D-mismatching both in visual analysis and in digitalized programed analysis (Syngo.via program). The neurologic outcomes were compared according to the presence of mismatch by image analysis method.

Results

Favorable outcome (mRS: 0~2), mortality, recanalization, and clinically significant hemorrhage rates were 56.3% (45/80), 6.25% (5/80), 81.3% (65/80), and 25% (20/80) in the MRI group, respectively; and 38.1% (24/63), 4.8% (3/63), 96.8% (61/63), and 47.6% (30/63) in the CTP group (p = 0.023, 0.498, 0.003, and 0.004). Compared to CTP analysis, digitized analysis showed more favorable outcome in the P/D-mismatch group (p=0.000) than in the visual mismatch group (p=0.237).

Conclusions

Recent papers reported that digitized CTP image analysis is as good as MR-based P/D-mismatch image analysis for patient selection in additional IA-Tx. However, in our study, P/D-mismatch from an MR image was better than CTP-based patient selection for those requiring additional IA-Tx to improve clinical outcomes.

Background and Aims

In order to develop a prognostic prediction model of EVT for AIS induced by LVO, the current study applied machine learning classfication model light gradient boosting machine (LightGBM) to construct unique prediction model.

Methods

A total of 973 patients were included and primary outcome was assessed with modified Rankin Scale (mRS) at 90 days and favorable outcome was defined using mRS 0-2 scores. Besides, LightGBM algorithm and Logistic regression (LR) were used to construct a prediction model. Then a prediction scale was further established and verified by both internal data and other external data.

Results

Twenty pre-surgical variables were analyzed using LR and LightGBM. The results of LightGBM algorithm indicated that the accuracy and precision of the prediction model was 73.77% and 73.16%, respectively. The area under the curves (AUC) was 0.824. Furthermore, the top 5 variables suggesting unfavorable outcomes were namely fasting blood glucose levels, age, onset to EVT time, onset to hospital time, and NIHSS scores (importance=130.9, 102.6, 96.5, 89.5 and 84.4, respectively). According to AUC curve, we established the key cut-off points and constructed prediction scale basing on their respective weightings. Then, the established prediction scale was verified in raw and external data and the sensitivity was 80.4% and 83.5%, respectively. Finally, the scores over 3 demonstrated better accuracy in predicting unfavorable outcomes.

Conclusions

In conclusion, pre-surgical prediction scale is feasible and accurate in identifying unfavorable outcomes of AIS after EVT.

Background and Aims

Intravenous thrombolysis(IVT) for acute ischemic stroke(AIS) is underused in China, which reflect the variation in clinical decision-making. We aimed to develop and validate a clinical score to identify factors contributing to variation in clinician's decision-making about treating AIS patients with IVT.

Methods

We retrospectively included consecutive AIS patients within 4.5 hours after onset from a comprehensive stroke center in China. The patients were categorized into two groups according to thrombolysis administration, who were further randomly divided into derivation (60%) and validation data sets (40%) to develop and validate the clinical score. Multivariable logistic regression was performed to identify the independent predictors of IVT offering.

Results

418 of 526 included patients were offered thrombolysis, while 108 were not. Nine patient factors were predictive of the likelihood of thrombolysis (age, time to hospital, NIHSS score, great vessel, facial paralysis, dizziness, headache, history of stroke, and neutrophil ratio). According to the constructed score, the patients were classified into 3 probability categories: low , intermediate and high. In the derivation cohort (n= 316), the thrombolysis rates in the three categories were 11.1%, 28.5%, and 38.0% (P<0.0001), while the rates were 16.2%, 27.6%, and 38.6% (P=0.02) in the internal validation data (n = 210). The c-statistics of the Intravenous Thrombolysis Score in the derivation cohort and validation cohort were 0.795 and 0.751, respectively.

Conclusions

The Intravenous Thrombolysis Score indicates clinicians differ in their thresholds for the treatment across a number of patient-related factors, which is linked to address the impact of non-medical influences on decision-making using evidence-based strategies.

Background and Aims

There are limited data on mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients with preexisting disability. We aimed to compare functional and safety outcomes of AIS patients with pre-stroke disability treated with MT compared to those receiving best medical treatment.

Methods

From the Austrian Stroke Unit registry and the ASTRAL registry, we included all consecutive acute ischemic stroke patients with pre-stroke disability, defined as modified Rankin Score (mRS) ≥3, and acute intracranial large vessel occlusion (LVO). Patients undergoing MT were compared to those receiving best medical treatment (BMT) by means of univariate and multivariate logistic regression analysis.

Results

We included in the study 462 AIS patients with pre-stroke mRS ≥3 and LVO. Among them, 175 underwent MT and 287 received BMT. Patients with MT were younger, had more severe strokes and lower pre-stroke mRS, but similar proportion of treatment with intravenous thrombolysis. On multivariate analysis, MT was associated with a higher probability of returning to baseline mRS at 3 months (aOR 2.5, CI 1.4-4.5) and early neurological improvement ≥8 NIHSS points (aOR 2.6, CI 1.4-4.9), as well as to a lower probability of 3-month poor outcome (aOR 0.4, CI 0.2-0.7) and mortality (aOR 0.3, CI 0.2-0.5).

Conclusions

Patients with pre-stroke mRS ≥3 treated with mechanical thrombectomy had better short-term and 3-month outcomes. This suggests that pre-stroke disability alone should not be a reason to withhold MT, but that individual case-by-case decisions may be more appropriate.

Background and Aims

To establish a clinical decision tool to evaluate the treatment benefit of endovascular thrombectomy with or without Intravenous alteplase among patients with acute ischemic stroke.

Methods

We established a “two-learner” modeling frame based on causal inference by respectively developing two predictive models using proportional odds regression for patients who received endovascular thrombectomy(EVT) alone versus who received additional treatment of intravenous alteplase (IVT+EVT). The model was established useing 656 patients' data from DIRECT-MT trial, and validated using 1492 patient data from MR-clean registry.

Results

Eight baseline clinical and neurological imaging characteristics were included as the covariates to model the functional outcome. External validation demonstrated moderate discriminative performance with the area under the ROC curve of 0.68 (95% CI 0.65 to 0.72) and 0.71 (95% CI 0.65 to 0.78) for shifted mRS predictive models established based on EVT alone group and IVT+EVT group, respectively. Patients who fell into the obedient group yielded 48.8% of good functional outcomes (90-day mRS 0-2) versus 34.3% for those who did not, achieving a decision benefit of 14.5% (one-sided p-value < 0.01).

Conclusions

We developed a clinical decision tool with several baseline characteristics readily obtained at the emergency department. It demonstrated significant decision benefits between the obedient and the disobedient groups in external validation cohorts. It may assist clinicians in making decisions upon adminstrating intravenous alteplase before endovascular thrombectomy.

Background and Aims

To characterize the frequency and types of intracranial hemorrhage in patients underwent endovascular thrombectomy with and without intravenous alteplase, and their association with patient outcome, to identify modifiable predictors that may allow for prevention.

Methods

We performed secondary analysis of the randomized DIRECT-MT trial comparing intravenous alteplase before thrombectomy versus thrombectomy only in large vessel occlusion stroke.Of 656 randomized patients, 591 who received thrombectomy were included. The incidences of any intracranial hemorrhage, symptomatic hemorrhage, and hemorrhage subtypes according to Heidelberg Bleeding Classification were compared between groups. Exporatory analyses were conducted to identify possible factors that may modify the treatment effect on hemorrhage or their subtypes

Results

Among 651 patients included, any intracranial hemorrhage occurred in 254(43.0%), including HI-1 in 12(2.0%), HI-2 in 127(21.7%), PH-1in 34(5.8%), PH-2 in 50(8.5%), and others(3a-3c) in 24(4.1%). A similar intracranial hemorrhage incidence was observed with thrombectomy only vs. combined alteplase and thrombectomy(134/292[45.9%] vs. 120/299[40.1%]; OR 1.27, 95%CI [0.91-1.75], P=0.16), but patients treated with alteplase had a higher PH incidence (51/287[17.8%] VS. 33/297[11.0%]; OR 1.72, 95%CI [1.01-2.79], P=0.030). This effect was modified by admission hyperglycemia (serum glucose ≥7.8mmol/L) in an exploratory analysis (P for interaction =0.04), in such a way that alteplase increased the risk of PH in patients in whom with admission hyperglycemia (OR 3.11, 95% CI [1.40-6.93]), but not in those without hyperglycemia(OR 1.10, 95%CI [0.58-2.09]).

Conclusions

In this secondary analysis of a Chinese trial, alteplase did not increase overall intracranial hemorrhage for large vessel occlusion patients treated with endovascular thrombectomy, but it increased the incidence of parenchymal hematoma.

Background and Aims

Hyperglycemia is associated with decreased recanalization possibility and increased risk of hemorrhagic complications for stroke patients treated with intravenous alteplase. However, whether hyperglycemia modifies alteplase treatment effect on clinical outcome in patients with large vessel occlusion stroke undergoing endovascular thrombectomy is uncertain. We conducted this study to determine a possible interaction effect between admission hyperglycemia and intravenous alteplase prior to thrombectomy in patients with large vessel occlusion stroke.

Methods

In this Post-hoc analysis of a randomized trial (DIRECT-MT) comparing intravenous alteplase before endovascular treatment vs. endovascular treatment only, 649 with available baseline glucose measurements were included. The treatment-by-admission hyperglycemia (defined as plasma glucose levels ≥7.8 mmol/L[140mg/dL]) interaction was assessed using logistic regression models.

Results

Among 649 patients included, 224(34.5%) were hyperglycemic at admission. There was evidence of alteplase treatment effect modification by hyperglycemia (P_interaction=0.025). In patients without hyperglycemia, combination therapy was associated with better outcomes compared to mechanical thrombectomy alone (adjusted common odd ratio[acOR] 1.46, 95% CI [1.04-2.07]), but not in hyperglycemic patients (acOR 0.74, 95% CI [0.46-1.20]). Combination therapy led to an absolute increase of 6% excellent outcome (mRS 0-1) in non-hyperglycemic patients (aOR 1.71,95% CI [1.05-2.79]), but resulted in a 12.3% absolute decrease (aOR 0.42, [95% CI, 0.19-0.95] in hyperglycemic patients (P_interaction=0.003).

Conclusions

For large vessel occlusion patients directly presenting to a thrombectomy-capable hospital, hyperglycemia modified combination treatment effect on clinical outcome. Combination therapy was beneficial in patients without hyperglycemia, while thrombectomy alone may be preferred in hyperglycemic patients. Further studies are needed to confirm this result.

Background and Aims

It is unclear whether intravenous thrombolysis (IVT) outperforms early dual antiplatelet therapy (DAPT) in the setting of mild ischemic stroke. The aim of this study was to compare early safety and efficacy of IVT as compared to DAPT

Methods

Data of mild non-cardioembolic stroke patients with admission NIHSS <=3 who received IVT or early DAPT in the period 2018-2021 were extracted from a nationwide, prospective stroke unit registry. Study endpoints included symptomatic intracerebral haemorrhage (sICH) according to ECASS3 criteria, early neurological deterioration ³4 NIHSS points (END) and 3-months functional outcome by modified Rankin Score (mRS).

Results

1195 mild stroke patients treated with IVT and 2625 treated with DAPT were included. IVT patients were younger (68.1 vs 70.8 years), had less hypertension (72.8% versus 83.5%), diabetes (19% versus 28.8%) and history of myocardial infarction (7.6% versus 9.2%) and slightly higher admission NIHSS scores (median 2 versus median 1) as compared to DAPT patients. After propensity score matching, IVT was associated with sICH (4 (1.2%) vs 0), END (aOR 2.8, CI 1.1-7.5), and mRS 0-1 at 3 months (aOR 1.3, CI 0.7-2.6).

Conclusions

This large non-randomized comparison derived from a nationwide stroke unit network indicates that IVT is not superior to DAPT in the setting of mild non-cardioembolic stroke and may eventually be associated with harm. Further research focusing acute therapy of mild stroke is highly warranted.

Background and Aims

Unruptured intracranial aneurysms (UIAs) represent a relative contraindication for intravenous thrombolysis (IVT) in acute ischemic stroke (AIS). However, presently few data on the risk of UIA rupture secondary to IVT are reported. The aim of our retrospective study was to assess whether IVT for AIS is associated with UIA rupture and intracranial hemorrhages (ICHs) in patients with unruptured UIAs.

Methods

We conducted a retrospective, single-center, observational study and included patients admitted to the Perugia Stroke Unit from January 2019 to December 2021. Patient inclusion criteria were an AIS, regardless of its location, and treatment with IVT. The group of cases consisted of patients with UIAs at the time of the AIS, while the controls had no UIAs.

Results

A total of 238 patients were collected: median age 76 yy (IQR 17), 102 F and 136 M

133/223 patients received IVT alone. 119 with no UIA, 14 with UIA.

Among patients with IVT, 52/192 patients with no history of UIAs experienced ICHs, while 1/19 patients with UIAs experienced any ICH (OR 0.15, CI 95% 0.02-1.15, p=0.070).

No significant differences in patient comorbidities were observed between patients with UIA or UIA treated with IVT. Admission NIHSS was lower in patients with UIA than in patients with no UIA (9.70±0.94 vs. 12.79±0.43, p=0.016)

Conclusions

One patient with UIAs experienced ICH after IVT treatment, which appears to be safe in patients with AIS, including large UIAs (≥10 mm).

Background and Aims

We aim to investigate the efficacy and safety of mechanical thrombectomy (MT) for medium vessel occlusion (MeVO)

Methods

Of the consecutive acute ischemic stroke (AIS) patients with prestroke modified Rankin Scale (mRS) score of 0–2 admitted to our institute from 2010 to 2021, AIS patients due to MeVO (middle cerebral artery [MCA] M2, M3, anterior cerebral artery A1, A2/A3, or posterior cerebral artery P2/P3 occlusion) within 24 hours of onset were enrolled. Outcomes including the favorable outcome (3-month mRS score of 0–2), mortality at 3-month, any intracerebral hemorrhage (ICH)within 36 h from onset, and symptomatic ICH (SICH) were assessed between patients receiving MT and standard medical treatment (SMT).

Results

Of 428 patients (167 women; median age, 77 years; median NIH Stroke Scale score [NIHSS] 9), 374 (84%) patients had MCA M2 occlusion. Patients who received MT (n=119) have a higher median NIHSS score (14 vs. 8, P<0.01), and more intravenous thrombolysis (55.5% vs. 36.5%, P<0.01) than those received SMT. There were no significant differences in the favorable outcome (57.1% vs. 54.8%, P=0.67), mortality at 3-month (5.9% vs. 3.4%, P=0.28), SICH (1.7% vs. 2.6%, P=0.73) between both groups, but any ICH within 36 h from onset were more frequent in patients received MT than those received SMT (41.9% vs. 27.5%, P<0.01). In patients with NIHSS score ≥10, favorable outcome was more frequent in patients received MT than those received SMT (adjusted odds ratio [aOR] 2.04, 95% confidence interval [CI] 1.17–3.57), but not in those with NIHSS score <10 (0.93, 0.44–1.98; P for interaction=0.10).

Conclusions

MT may be more effective than SMT for a part of MeVO.

Background and Aims

Although tirofiban and endovascular thrombectomy both have been wildly used in treatment of acute ischemic stroke (AIS) , the effect of their combined application remains controversial. Here, we evaluate the efficacy and safety of tirofiban on direct endovascular therapy (DEVT) for AIS in anterior circulation vessels occlusion.

Methods

A total of 204 patients undergoing DEVT for AIS with anterior circulation vessels occlusion from four hospitals were enrolled in this retrospective database from January 2020 to December 2021. And the primary efficacy endpoint was evaluated by 90 d modified Rankin Scale (mRS) and functional independence was defined as 0-2 scores. And the safety endpoint was assessed by symptomatic intracerebral hemorrhage (sICH) and mortality.

Results

Coincidentally, tirofiban and non-tirofiban group included 102 patients, respectively. Compared with non-tirofiban group, the 90 d-mRS favourable outcomes rate in tirofiban group was significantly higher (53.9% versus 35.2%, P=0.007). However, the sICH and 90-d mortality rate were lower in tirofiban group despite a lack of statistical significance (sICH rate, 15.7% in tirofiban group versus 16.7% in non-tirofiban group, P=0.849; 90-d mortality rate, 16.67% in tirofiban group versus 24.51% in non-tirofiban group, P=0.166). Finally, it was found that patients with the following factors tend to benefit more from tirofiban treatment: advanced age older than 72 y, male, admission NIHSS score higher than 14, time from onset to reperfusion longer than 327 min and medical history of diabetes.

Conclusions

Administration of tirofiban after DEVT improve the functional outcomes of AIS and decrease the 90-d mortality rate in anterior circulation vessels occlusion.

Background and Aims

It remains uncertain whether minor acute ischemic stroke (AIS) patients with large vessel occlusion (LVO) benefit from endovascular treatment (EVT). We aim to evaluate the outcomes of EVT in minor AIS with anterior circulation LVO.

Methods

Based on a nationwide prospective stroke registry, minor AIS with anterior circulation LVO within 24 hours of onset were divided into groups receiving standard medical treatment (SMT) plus EVT or SMT alone. Primary outcome was excellent functional outcome defined as modified Rankin Scale score 0-1 at 90 days. In addition, a multivariable logistic regression model was used to analyze the effect of EVT guided by perfusion imaging.

Results

A total of 572 patients with median age 68 years (interquartile range [IQR] = 60-77) and median NIHSS 3 (IQR = 2-4) were identified and 123 patients were treated with SMT plus EVT. EVT was not associated with excellent functional outcome (OR 0.793; 95% CI 0.515-1.219; P = 0.290). However, therapy selection guided by perfusion imaging was a modifier of EVT effect on outcomes, as EVT was independently associated with excellent functional outcome (60.0% vs 50.8%, OR 2.849; 95% CI 1.006-8.067; P = 0.049), but not with symptomatic intracerebral hemorrhage in the imaging-guided group.

Conclusions

Although functional outcomes in minor AIS due to anterior circulation LVO were not improved from the routine use of EVT, our results suggested that EVT guided by perfusion imaging could be beneficial for those patients.