Search

Background: Small, randomized trials of patients with cervical artery dissection showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with cervical artery dissection treated with antiplatelets versus anticoagulation., Methods: This is a multicenter observational retrospective international study (16 countries, 63 sites) that included patients with cervical artery dissection without major trauma. The exposure was antithrombotic treatment type (anticoagulation versus antiplatelets), and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with inverse probability of treatment weighting to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an as-treated crossover approach and only included outcomes occurring with the above treatments., Results: The study included 3636 patients (402 [11.1%] received exclusively anticoagulation and 2453 [67.5%] received exclusively antiplatelets). By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with inverse probability of treatment weighting, compared with antiplatelet therapy, anticoagulation was associated with a nonsignificantly lower risk of subsequent ischemic stroke by day 30 (adjusted hazard ratio [HR], 0.71 [95% CI, 0.45-1.12]; P =0.145) and by day 180 (adjusted HR, 0.80 [95% CI, 0.28-2.24]; P =0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR, 1.39 [95% CI, 0.35-5.45]; P =0.637) but was by day 180 (adjusted HR, 5.56 [95% CI, 1.53-20.13]; P =0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR, 0.40 [95% CI, 0.18-0.88]; P interaction =0.009)., Conclusions: Our study does not rule out the benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings., Competing Interests: Disclosures Disclosures provided by Dr Nguyen in compliance with American Heart Association annual Journal Editor Disclosure Questionnaire are available at https://www.ahajournals.org/editor-coi-disclosures. Dr Arnold reports compensation from Boehringer Ingelheim, AstraZeneca, Bayer, Bristol-Myers Squibb, Covidien, Daiichi Sankyo, Novartis, Sanofi, Pfizer, Medtronic, Novo Nordisk, and Amgen for consultant services. Dr Lester reports a provisional patent for Methods and compositions for disrupting tau aggregates. Dr Touze reports compensation from Elsevier for other services and employment by Caen. J.E. Kaufman reports grants from Goldschmidt Jacobson-Stiftung. Dr Traenka reports travel support from Bayer Healthcare. Dr Aguiar de Sousa reports compensation from Daiichi Sankyo, Bayer, AstraZeneca, Johnson & Johnson, and Fundação Bial for other services; compensation from the University of British Columbia for data and safety monitoring services; compensation from Organon & Co for consultant services. Dr Rosa reports grants from Merck Sharp & Dohme Corporation. Dr Field reports compensation from HLS Therapeutics, AstraZeneca Canada, and Roche for consultant services; service as a board member for Destine Health; and compensation from the Canadian Medical Protective Association for expert witness services; and grants from Bayer. Dr Leker reports compensation from Medtronic, Ischemaview, Bayer, Abbott Diabetes Care, Biogen, Janssen Biotech, and Boehringer Ingelheim for other services. Dr Nolte reports compensation from Daiichi Sankyo Europe GmbH, Boehringer Ingelheim, Pfizer, Bristol-Myers Squibb, and Alexion Pharmaceuticals for consultant services; and compensation from AstraZeneca, Abbott Canada, Deutsches Zentrum für Neurodegenerative Erkrankungen, Novartis, Portola Pharmaceuticals, Deutsches Zentrum für Herz-Kreislaufforschung, and Novartis for other services. Dr Poppe reports grants from Foundation Brain Canada, Heart and Stroke Foundation of Canada, and Stryker; and compensation from Roche for other services. Dr Liebeskind reports compensation from Medtronic, Genentech, Cerenovus, Stryker, and Rapid Medical Ltd, for consultant services. B. Mac Grory reports grants from the National Institutes of Health; employment by Duke University Medical Center; compensation from Bayer for other services; grants from the American Heart Association, Duke Bass Connections, and the Duke Office of Physician Scientist Development. Dr Al Kasab reports compensation from Stryker for other services and employment by Medical University of South Carolina. Dr Kicielinski reports compensation from Stryker, Penumbra Inc, Medtronic, and MicroVention Inc, for other services; travel support from MicroVention Inc; and employment by Medical University of South Carolina and Elsevier. Dr de Havenon reports stock options in TitinKM and Certus; grants from the National Institutes of Health; and compensation from Novo Nordisk for consultant services. Dr Siegler reports grants from Philips and employment by the University of Chicago. Dr Willey reports compensation from Edwards Lifesciences Corporation and Abbott Fund for end point review committee services; compensation from Uptodate for other services; and compensation from the Abbott Laboratories for consultant services. Dr Sharma reports a provisional patent for a stroke etiology classifier algorithm and grants from the National Institutes of Health Clinical Center. Dr Martins reports compensation from Pfizer, Medtronic, Servier Affaires Medicales, Daiichi Sankyo, Bayer, Novo Nordisk, Novartis, Penumbra Inc, and Boehringer Ingelheim for other services. Dr Simpkins reports grants from the National Institutes of Health. Dr Stretz reports grants from Massachusetts General Hospital. Dr Furie reports compensation from Janssen Biotech for consultant services. The other authors report no conflicts

Background: The transradial approach (TRA) for neurointerventional procedures is increasingly being used given its technical feasibility and safety. However, catheter trackability and device deliverability are reported barriers to TRA adoption., Methods: This is the first report describing the technical feasibility and performance of using the Zoom RDL Radial Access System (Imperative Care, Inc., Campbell, CA) in 29 patients who underwent neurointerventional procedures from October 2022 to January 2023 in a single-center institution., Results: Mean age of the study population was 61.9±17.2 years, 79.3% were male (23/29), and 62.1% were black (18/29). The most common procedures were stroke thrombectomy (31.0%, 9/29) and aneurysm embolization (27.6%, 8/29). All the stroke thrombectomy procedures were successfully performed; first-pass effect rate (mTICI≥2 c in one pass) was achieved in 66.7% (6/9) of cases. We used TRA in 86.2% of cases (25/29), including distal radial/snuffbox access in 31.0% (9/29) of cases. The radial diameter was >2 mm for all cases. An intermediate/aspiration catheter was used in 89.7% (26/29) of cases. Access success was achieved in 89.7% of cases (26/29); two cases required conversion from TRA to transfemoral approach (6.9%) and one case required conversion to a different guide catheter (3.4%). There were no access site complications or other Zoom RDL-related complications. One intracerebral hemorrhage, and one procedure-related thrombus were observed., Conclusions: The use of Zoom RDL Radial Access System is technically feasible and effective for complex neurointerventional procedures with low complication rates., Competing Interests: Competing interests: TK – Brainomix: Consultant, Cerenovus: Consultant, Imperative Care: Consultant, Medtronic Inc.: Consultant, Microvention: Consultant, Stryker Neurovascular: Consultant. The remaining authors declared no competing interests., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Intracranial atherosclerotic stenosis is a prevalent cause of ischemic stroke worldwide. Its association with silent cerebral infarcts and its contribution to cognitive impairment and dementia emphasize the critical need for disease prevention and effective management strategies. Despite extensive research on secondary stroke prevention treatment over the past several decades, intracranial atherosclerotic stenosis continues to exhibit a notably higher recurrent stroke rate compared with other causes. This review focuses on randomized secondary prevention trials involving antithrombotic therapy, endovascular treatment, open surgical therapy, and remote ischemic conditioning. It aims to provide an insightful overview of the major findings from each trial and their implications for future research efforts., Competing Interests: Disclosures None.

Background: There is unclear added benefit of intravenous thrombolysis (IVT) with endovascular thrombectomy (EVT). We performed a cost-effectiveness analysis to assess the cost-effectiveness of comparing EVT with IVT versus EVT alone., Methods: We used a decision tree to examine the short-term costs and outcomes at 90 days after the occurrence of index stroke to compare the cost-effectiveness of EVT alone with EVT plus IVT for patients with stroke. Subsequently, we developed a Markov state transition model to assess the costs and outcomes over 1-year, 5-year, and 20-year time horizons. We estimated total and incremental cost, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio., Results: The average costs per patient were estimated to be $47,304, $49,510, $59,770, and $76,561 for EVT-only strategy and $55,482, $57,751, $68,314, and $85,611 for EVT with IVT over 90 days, 1 year, 5 years, and 20 years, respectively. The cost saving of EVT-only strategy was driven by the avoided medication costs of IVT (ranging from $8,178 to $9,050). The additional IVT led to a slight decrease in QALY estimate during the 90-day time horizon (loss of 0.002 QALY), but a small gain over 1-year and 5-year time horizons (0.011 and 0.0636 QALY). At a willingness-to-pay threshold of $50,000 per QALY gained, the probabilities of EVT only being cost-effective were 100%, 100%, and 99.3% over 90-day, 1-year, and 5-year time horizons., Conclusion: Our cost-effectiveness model suggested that EVT only may be cost-effective for patients with acute ischemic stroke secondary to large vessel occlusion., (© 2023 S. Karger AG, Basel.)

Background: About 30 % of stroke patients have experienced unsuccessful reperfusion following endovascular therapy. Mechanical thrombectomy instruments may contribute to this by stimulating platelet aggregation. Tirofiban is a selective and rapidly activated antagonist of the platelets nonpeptide glycoprotein IIb/IIIa receptors that can reversibly suppress platelet aggregation. But, data from the medical literature are conflicting regarding its safety and efficacy for stroke patients. Hence, this study was designed to assess the safety and efficacy of tirofiban in stroke patients., Methods: Five major databases (PubMed, Scopus, Web of Science, Embase, and Cochrane library) were searched till December 2022. The Cochrane tool was used for risk of bias assessment, and the RevMan 5.4 was utilized for data analysis., Results: Seven RCTs with 2088 stroke patients were included. Tirofiban significantly increased the number of patients with mRS 0 score after 90 days than control; RR= 1.39, 95 %CI [1.15, 1.69]; p = 0.0006. Additionally, it reduced the NIHSS score after seven days; MD= -0.60, 95 %CI [-1.14, -0.06]; p = 0.03. However, tirofiban increased the incidence of intracranial haemorrhage (ICH); RR= 1.22, 95 %CI [1.03, 1.44]; p = 0.02. Other assessed outcomes showed insignificant results., Conclusions: Tirofiban was associated with a higher mRS 0 score after three months and a lower NIHSS score after seven days. However, it is associated with higher ICH. Multicentric trials are required to provide more convincing proof of its utility., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2023 The Authors. Published by Elsevier B.V. All rights reserved.)

Background: Thrombectomy for basilar artery occlusion (BAO) has proven efficacy in patients with moderate-to-severe deficits, but has unclear benefits for those with mild symptoms., Methods: Using an observational cohort design, the US National Inpatient Sample (2018-2020) was queried for adult patients with basilar artery occlusion and National Institutes of Health Stroke Scale (NIHSS) <10 for patients treated with thrombectomy versus medical management. The primary outcome of routine discharge (to home or self-care) was evaluated using multivariable logistic regression and propensity score matching, adjusted for baseline characteristics, stroke severity, and treatment with thrombolysis., Results: Of 17 019 with basilar artery occlusion, 5795 patients met the criteria for inclusion criteria for our study, and 880 (15.4%) were treated with endovascular thrombectomy. In the propensity score-matched cohort, 880 patients were treated with medical management and endovascular thrombectomy, respectively. In multivariable regression, endovascular thrombectomy was associated with both an increased odds of routine discharge (odds ratio, 1.95 [95% CI, 1.31-2.90]; P =0.001) and a decreased length of hospital stay (B, -0.74 [95% CI, -1.36 to -0.11]; P =0.02) compared with medical management. In the propensity score matched cohort, endovascular thrombectomy remained associated with greater odds of routine discharge (2.01 [95% CI, 1.21-3.34]; P =0.007) but no difference in length of hospital stay (B, -0.22 [95% CI, -0.90 to 0.46]; P =0.53)., Conclusions: Routine discharge was more common in this representative US cohort of patients with basilar artery occlusion and National Institutes of Health Stroke Scale <10 who underwent thrombectomy compared to conventional medical management. These findings suggest thrombectomy may be associated with better functional outcomes despite lower National Institutes of Health Stroke Scale and should be validated in a clinical trial setting., Competing Interests: Disclosures Dr Nguyen reports research support from SVIN and Medtronic; advisory board with Idorsia. S. Yaghi reports research support from Medtronic. Dr Prabhakaran reports research support from National Institute of Neurological Disorders and Stroke, Agency for Healthcare Research and Quality; royalties from UpToDate; consultant fees from Wolters Kluwer Health Inc. The other authors report no conflicts.

Introduction: Current published guidelines and meta-analyses comparing endovascular thrombectomy (EVT) alone versus EVT with bridging intravenous thrombolysis (IVT) suggest that EVT alone is non-inferior to EVT with bridging thrombolysis in achieving favourable functional outcome. Because of this controversy, we aimed to systematically update the evidence and meta-analyse data from randomised trials comparing EVT alone versus EVT with bridging thrombolysis, and performed an economic evaluation comparing both strategies., Methods and Analysis: We will conduct a systematic review of randomised controlled trials comparing EVT with or without bridging thrombolysis in patients presenting with large vessel occlusions. We will identify eligible studies by systematically searching the following databases from inception without any language restrictions: MEDLINE (through Ovid), Embase and the Cochrane Library. The following criteria will be used to assess eligibility for inclusion: (1) adult patients ≥18 years old; (2) randomised patients to EVT alone or to EVT with IVT; and (3) measured outcomes, including functional outcomes, at least 90 days after randomisation. Pairs of reviewers will independently screen the identified articles, extract information and assess the risk of bias of eligible studies. We will use the Cochrane Risk-of-Bias tool to evaluate risk of bias. We will also use the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty in evidence for each outcome. We will then perform an economic evaluation based on the extracted data., Ethics and Dissemination: This systematic review will not require a research ethics approval because no confidential patient data will be used. We will disseminate our findings by publishing the results in a peer-reviewed journal and via presentation at conferences., Prospero Registration Number: CRD42022315608., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Stroke contributes an estimated $28 billion to US health care costs annually, and alternative payment models aim to improve outcomes and lower spending over fee-for-service by aligning economic incentives with high value care. This systematic review evaluates historical and current evidence regarding the impacts of alternative payment models on stroke outcomes, spending, and utilization. Included studies evaluated alternative payment models in 4 categories: pay-for-performance (n=3), prospective payments (n=14), shared savings (n=5), and capitated payments (n=14). Pay-for-performance models were not consistently associated with improvements in clinical quality indicators of stroke prevention. Studies of prospective payments suggested that poststroke spending was shifted between care settings without consistent reductions in total spending. Shared savings programs, such as US Medicare accountable care organizations and bundled payments, were generally associated with null or decreased spending and service utilization and with no differences in clinical outcomes following stroke hospitalizations. Capitated payment models were associated with inconsistent effects on poststroke spending and utilization and some worsened clinical outcomes. Shared savings models that incentivize coordination of care across care settings show potential for lowering spending with no evidence for worsened clinical outcomes; however, few studies evaluated clinical or patient-reported outcomes, and the evidence, largely US-based, may not generalize to other settings.

Background and Purpose: Higher reperfusion rates have been established with endovascular treatment of acute ischemic stroke (AIS). There are limited data on the comparative performance of mechanical thrombectomy devices., Methods: A retrospective single-center analysis was undertaken of all consecutive patients who underwent thrombectomy using Merci, Penumbra or stent retrievers (SR) from September 2010 to November 2012. Baseline characteristics, rates of successful recanalization (modified Thrombolysis in Cerebral Infarction (mTICI) score 2b-3), symptomatic intracerebral hemorrhage (sICH), final infarct volume, 90-day mortality and independent functional outcomes at 90 days were compared across the three devices., Results: Our cohort included 287 patients. There were mild imbalances in baseline characteristics with trends towards higher National Institutes of Health Stroke Scale (NIHSS) score in patients in the Merci group (SR=18 vs Merci=21 vs Penumbra=19, p=0.06) and lower Alberta Stroke Program Early CT Score (ASPECTS) in patients in the SR group (>7: SR=51% vs Merci=61% vs Penumbra=62%, p=0.12). On univariate analysis there were no differences in the rate of sICH (SR=7% vs Merci=7% vs Penumbra=6%, p=0.921) and infarct volume (SR=61.5 mL vs Merci=69.5 mL vs Penumbra=59.2 mL, p=0.621). Trends towards better functional outcomes were found with Penumbra and SR vs Merci (41% vs 36% vs 25%, respectively, p=0.079). Complete or near complete reperfusion (mTICI 2b-3) was higher in the SR and Penumbra groups than in the Merci group (86% vs 78% vs 70%, respectively, p=0.027). Binary logistic regression showed that SR was an independent predictor of good functional outcome (OR 2.27, 95% CI 1.018 to 5.048; p=0.045)., Conclusions: Although our initial data confirm the superiority of SR technology over the Merci device, there was no significant difference in near complete/complete reperfusion, final infarct volumes or clinical outcomes between SR and Penumbra thromboaspiration., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Large vessel occlusions with heavy clot burden are less likely to improve with intravenous (IV) thrombolysis alone. The purpose of this study was to show whether a combination of IV thrombolysis and endovascular therapy was superior to endovascular treatment alone., Methods: Data for 104 patients with acute large artery occlusion treated between 2005 and 2010 were reviewed. Forty-two received endovascular therapy in combination with IV thrombolysis (bridging group), and 62 received endovascular therapy only. Clinical outcome, mortality rate, and symptomatic intracranial hemorrhage (sICH) rate were compared between the two groups., Results: The two groups had similar demographic and vascular risk factor distribution, as well as National Institutes of Health Stroke Scale score on admission (mean±SD: 14.8±4.7 and 16.0±5.3; P=0.23). No difference was found in Thrombolysis in Myocardial Infarction recanalization rates (score of 2 or 3) after combined or endovascular therapy alone (83.33% and 79.03%; P=0.585). Favorable outcome, defined as a modified Rankin Scale score of <2 at 90 days, also did not differ between the bridging group and the endovascular-only group (37.5% and 32.76%; P=0.643). There was no difference in mortality rate (19.04% and 29.03%; P=0.5618) and sICH rate (11.9% and 9.68%; P=0.734). A significant difference was found in mean time from symptom onset to treatment in the bridging group and the endovascular-only group (227±88 min vs. 125±40 min; P<0.0001)., Conclusion: Combining IV thrombolysis with endovascular therapy resulted in similar outcome, revascularization, sICH, and mortality rates compared with endovascular therapy alone. Prospective clinical studies comparing both treatment strategies in acute ischemic stroke are warranted., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Objective: Acute ischemic stroke due to proximal intracranial vessel occlusion is associated with poor prognosis and neurologic outcomes. Outcomes specifically in patients with stroke due to these occlusions and lower National Institutes of Health Stroke Scale (NIHSS) scores (0-7 range) have not been described previously., Methods: We retrospectively reviewed discharge outcomes (reported in our 'Get With the Guidelines-Stroke' database) in patients with an admission NIHSS score of 0-7 due to proximal intracranial large vessel occlusion (based on CT angiography results) who were excluded from receiving intravenous (IV) thrombolysis with recombinant tissue plasminogen activator and endovascular intra-arterial (IA) stroke interventions., Results: Among the 204 patients included in our analysis, younger age and lower admission NIHSS score (0-4 range) were strong predictors of good outcome (defined as ability to ambulate independently) at discharge whereas female sex was a predictor of poor outcome. There was no significant difference between cerebrovascular risk factors, specific sites of occlusion, or presenting symptoms and outcomes at discharge. There was great variability in functional outcomes at discharge and discharge disposition (home versus acute or subacute facility or nursing home versus death/hospice) with a trend toward worse outcomes in patients with higher (5-7 range) NIHSS scores on admission., Conclusions: Patients with acute stroke due to large vessel occlusion and low admission NIHSS scores (0-7 range) may have poor functional outcomes at discharge. These patients, if not eligible for IV thrombolysis, might benefit from IA revascularization therapies., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: Cerebral protection device utilization during carotid artery stenting (CAS) has been shown to decrease risk of perioperative stroke. The two most commonly used devices are distal filters and proximal protection devices, which allow blood flow cessation or flow reversal. The goal of the present study was to examine anatomic and morphologic characteristics of the treated lesions using each type of cerebral protection device and compare clinical 30-day adverse event rates between the two cerebral protection groups., Methods: We conducted a single-center, retrospective review of consecutive CAS cases with proximal protection devices that were matched with CAS cases using distal filter protection devices based on indication (symptomatic vs. asymptomatic), age, and gender. We reviewed clinical, anatomic, and morphologic characteristics of the stented lesions in cases of proximal or distal protection and also studied the rate of major adverse events within the first 30 days after the procedure., Results: We identified a total of 70 patients treated with proximal protection devices who were matched in a blinded fashion to 70 cases with distal protection. There was a significantly higher number of high-risk lesions in patients who had CAS using proximal protection devices (P = 0.009). There was no significant difference in overall frequency of 30-day adverse outcomes (transient ischemic attack/stroke/reperfusion hemorrhage/death) between the two groups (P = 1.0)., Conclusions: Our study is the first attempt (to our knowledge) to review and compare anatomic and morphologic characteristics of the stented lesions in cases of proximal versus distal protection for CAS. Our data indicate that in properly selected patients both approaches could be equally safe and effective., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background and Objectives: Current American Stroke Association/American Heart Association recommendations on the management of acute ischemic stroke do not recommend the early use of heparin because of an increased risk of bleeding complications. However, for select patients, such as those with strokes associated with non-occlusive intraluminal thrombus, intravenous heparin might prove to be beneficial., Methods: A retrospective analysis of acute ischemic stroke cases associated with non-occlusive intraluminal thrombus of intracranial and extracranial arteries in the corresponding vascular territories was conducted to identify patients in whom treatment with intravenous heparin resulted in near-complete or complete lysis of the thrombus. Imaging findings from CT perfusion and angiography, MRI, and/or digital subtraction angiography were used to describe the location of intraluminal thrombus immediately before and after treatment with intravenous heparin., Results: 18 patients with nonocclusive intraluminal thrombus confirmed by CT angiography (CTA) received treatment with intravenous heparin alone (median duration 3.5 days; range 1-8 days). The median National Institutes of Health stroke scale score was 2.5 (range 0-15) on admission and 1 (range 0-9) at discharge. Nine patients had complete lysis, and nine patients had partial lysis of the thrombus with improved flow distal to the location of the thrombus. None of the patients developed intracranial hemorrhage., Conclusion: For strokes associated with intraluminal thrombus, intravenous heparin might prove to be an effective treatment strategy. Further studies are necessary to evaluate the efficacy and safety of treatment with intravenous heparin in those patients.

Extracranial carotid artery disease is commonly seen in patients presenting with stroke symptoms. It is also a frequent incidental finding in patients undergoing evaluation as part of a routine examination in the outpatient setting. Several diagnostic imaging modalities are currently available. Treatment strategies include medical and surgical management. Multiple randomized trials conducted over the past decade have laid a foundation for guidelines on the management of extracranial carotid disease. Evaluation and treatment of patients with vertebral artery stenosis is less understood. We review the evidence for the detection and treatment of patients with extracranial carotid artery and vertebral artery disease., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Background: There is limited knowledge on the radiographic features of thrombolysis-induced hemorrhage. The factors that influence early hematoma expansion have not been elucidated., Methods: Patients presenting with a symptomatic intracerebral hemorrhage (ICH) as a result of intravenous (IV) thrombolysis with tissue plasminogen activator (tPA) for acute ischemic stroke and had noncontrast computed tomographic (CT) scans of the head were included in this retrospective study. Calculation of hematoma volumes was obtained. Analysis of covariance was used to evaluate for the effect of baseline blood pressure (BP) on initial hematoma volume and further growth., Results: Of 267 patients who were treated with intravenous tPA for acute ischemic stroke at our facility between January 1, 2005 and December 31, 2009, 17 patients developed symptomatic ICH and were included in the final analysis. There was a positive correlation between baseline level of systolic BP after thrombolysis and initial hematoma volume (r = 0.46; P = .03) but not for the diastolic BP (r = 0.07; P = .40). There was a significant increase in mean hematoma volume expansion when comparing results between the first and second CT scans (median 9 hours, 22 minutes; 14.9 ± 19.6 cm(3) to 26.0 ± 26.7 cm(3); P = .04). There was also a negative association between the reduction of systolic BP and hematoma growth (r = -0.67; P = .02), but no correlation with change in diastolic BP (r = -0.22; P = .28)., Conclusions: Once diagnosed, thrombolysis-induced symptomatic ICH undergoes significant early expansion in size. Systolic BP may play a role in hematoma expansion., (Copyright © 2012 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

In patients undergoing endovascular therapy for acute ischemic stroke, antithrombotic therapies are utilized to prevent distal embolization, arterial reocclusion, or catheter-related embolism. However, this must be weighed against the risk of hemorrhagic complications secondary to existing and ongoing ischemia or silent vessel perforation. In this article, we present an overview of the available literature evaluating antithrombotic therapy in patients undergoing endovascular therapy for acute ischemic stroke and discuss the emerging role of these agents.

Background and Purpose: Strokes secondary to acute internal carotid artery (ICA) occlusion are associated with extremely poor prognosis. The best treatment approach to acute stroke in this setting is unknown. We sought to determine clinical outcomes in patients with acute ischemic stroke attributable to ICA occlusion treated with intravenous (IV) systemic thrombolysis or intra-arterial endovascular therapy., Methods: Using the PubMed database, we searched for studies that included patients with acute ischemic stroke attributable to ICA occlusion who received treatment with IV thrombolysis or intra-arterial endovascular interventions. Studies providing data on functional outcomes beyond 30 days and mortality and symptomatic intracerebral hemorrhage (sICH) rates were included in our analysis. We compared the proportions of patients with favorable functional outcomes, sICH, and mortality rates in the 2 treatment groups by calculating χ(2) and confidence intervals for odds ratios., Results: We identified 28 studies with 385 patients in the IV thrombolysis group and 584 in the endovascular group. Rates of favorable outcomes and sICH were significantly higher in the endovascular group than the IV thrombolysis-only group (33.6% vs 24.9%, P=0.004 and 11.1% vs 4.9%, P=0.001, respectively). No significant difference in mortality rate was found between the groups (27.3% in the IV thrombolysis group vs 32.0% in the endovascular group; P=0.12)., Conclusions: According to our systematic review, endovascular treatment of acute ICA occlusion results in improved clinical outcomes. A higher rate of sICH after endovascular treatment does not result in increased overall mortality rate.

Intracerebral hemorrhage (ICH) secondary to intravenous and intraarterial revascularization strategies for emergent treatment of acute ischemic stroke is associated with high mortality. ICH from systemic thrombolysis typically occurs within the first 24-36 hours of treatment initiation and is characterized by rapid hematoma development and growth. Pathophysiological mechanisms of revascularization therapy-induced ICH are complex and involve a combination of several distinct processes, including the direct effect of thrombolytic agents, disruption of the blood-brain barrier secondary to ischemia, and direct vessel damage from wire and microcatheter manipulations during endovascular procedures. Several definitions of ICH secondary to thrombolysis currently exist, depending on clinical or radiological characteristics used. Multiple studies have investigated clinical and laboratory risk factors associated with higher rates of ICH in this setting. Early ischemic changes seen on noncontrast CT scanning are strongly associated with higher rates of hemorrhage. Modern imaging techniques, particularly CT perfusion, provide rapid assessment of hemodynamic parameters of the brain. Specific patterns of CT perfusion maps can help identify patients who are likely to benefit from revascularization or to develop hemorrhagic complications. There are no established guidelines that describe management of revascularization therapy-induced ICH, and great variability in treatment protocols currently exist. General principles that apply to the management of spontaneous ICH might not be as effective for revascularization therapy-induced ICH. In this article, the authors review current knowledge of risk factors and radiological predictors of ICH secondary to stroke revascularization techniques and analyze medical and surgical management strategies for ICH in this setting.

Objectives: The main objective of this study was to develop and validate a computer-based statistical algorithm that could be translated into a simple scoring system in order to ascertain incident stroke cases using hospital admission medical records data., Methods: The Risk Index Score (RISc) algorithm was developed using data collected prospectively by the Brain Attack Surveillance in Corpus Christi (BASIC) project, 2000. The validity of RISc was evaluated by estimating the concordance of scoring system stroke ascertainment to stroke ascertainment by physician and/or abstractor review of hospital admission records., Results: RISc was developed on 1718 randomly selected patients (training set) and then statistically validated on an independent sample of 858 patients (validation set). A multivariable logistic model was used to develop RISc and subsequently evaluated by goodness-of-fit and receiver operating characteristic (ROC) analyses. The higher the value of RISc, the higher the patient's risk of potential stroke. The study showed RISc was well calibrated and discriminated those who had potential stroke from those that did not on initial screening., Conclusion: In this study we developed and validated a rapid, easy, efficient, and accurate method to ascertain incident stroke cases from routine hospital admission records for epidemiologic investigations. Validation of this scoring system was achieved statistically; however, clinical validation in a community hospital setting is warranted.