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INTRODUCTION: In patients with acute ischemic stroke (AIS) secondary to intracranial large vessel occlusion (LVO), optimal blood pressure (BP) management following endovascular treatment (EVT) has not yet been established. The randomized trial on Hemodynamic Optimization of cerebral Perfusion after successful Endovascular therapy in patients with acute ischemic stroke (HOPE) (clinicaltrials.gov id: NCT04892511), aims to demonstrate whether hemodynamic optimization using different systolic BP targets following EVT according to the degree of final recanalization, is more effective than currently recommended BP management in improving functional outcomes of patients with AIS. METHODS: HOPE is an investigator-initiated multicentre clinical trial with randomized allocation, open label treatment, and blinded endpoint evaluation (PROBE). Patients with an anterior circulation AIS within 24h of symptom onset, treated with EVT, and showing successful recanalization (mTICI ≥2b) at the end of the procedure, are equally allocated (1:1) to hemodynamic optimization according to the study protocol vs. BP management according to current guidelines (≤180/105mmHg). The protocol includes two different targets of systolic BP depending on the recanalization status (mTICI=2b: 140-160 mmHg; mTICI=2c/3: 100-140 mmHg). The protocol is applied within the first 72h and includes BP lowering as well as vasopressor therapies when needed. The primary outcome is the proportion of favorable outcome (modified Rankin Scale [mRS] 0-2) at 90 days. Secondary outcomes include the shift on the mRS score, neurological deterioration, symptomatic intracerebral haemorrhage and mortality. CONCLUSION: The HOPE trial will provide new information on the safety and efficacy of different BP targets following EVT according to the degree of final recanalization in patients with AIS.
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Background and Purpose: We aimed to determine the prevalence and predictors of delayed neurological improvement (DNI) after complete endovascular reperfusion in anterior circulation acute ischemic stroke (AIS). Methods: Retrospective analysis of an online multicenter prospective reperfusion registry of patients with consecutive anterior circulation AIS treated with endovascular thrombectomy (EVT) from January 2018 to June 2019 in tertiary stroke centers of the NORDICTUS (NORD-Spain Network for Research and Innovation in ICTUS) network. We included patients with AIS with a proximal occlusion in whom a modified Thrombolysis in Cerebral Infarction 3 reperfusion pattern was obtained. DNI was defined if, despite absence of early neurological improvement during the first 24 hours, patients achieved functional independence on day 90. Clinical and radiological variables obtained before EVT were analyzed as potential predictors of DNI. Results: Of 1565 patients with consecutive AIS treated with EVT, 1381 had proximal anterior circulation occlusions, 803 (58%) of whom achieved a modified Thrombolysis in Cerebral Infarction 3. Of these, 628 patients fulfilled all selection criteria and were included in the study. Mean age was 73.8 years, 323 (51.4%) were female, and median baseline National Institutes of Health Stroke Scale was 16. Absence of early neurological improvement was observed in 142 (22.6%) patients; 32 of these (22.5%) achieved good long-term outcome and constitute the DNI group. Predictors of DNI in multivariable-adjusted logistic regression were male sex (odds ratio, 6.4 [95% CI, 2.122.3] P=0.002), lower pre-EVT National Institutes of Health Stroke Scale score (odds ratio, 1.4 [95% CI, 1.21.5], P<0.001), and intravenous thrombolysis (odds ratio, 9.1 [95% CI, 2.730.90], P<0.001). Conclusions: One-quarter of patients with anterior circulation AIS who do not clinically improve within the first 24 hours after complete cerebral endovascular recanalization will achieve long-term functional independence, regardless of the poor early clinical course. Male sex, lower initial clinical severity, and use of intravenous thrombolysis before EVT predicted this clinical pattern.
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Isquemia Encefálica/cirugía , Revascularización Cerebral/tendencias , Procedimientos Endovasculares/tendencias , Accidente Cerebrovascular Isquémico/cirugía , Enfermedades del Sistema Nervioso/cirugía , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico por imagen , Revascularización Cerebral/métodos , Procedimientos Endovasculares/métodos , Femenino , Estudios de Seguimiento , Humanos , Accidente Cerebrovascular Isquémico/diagnóstico por imagen , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/diagnóstico por imagen , Estudios Prospectivos , Sistema de Registros , Estudios RetrospectivosRESUMEN
INTRODUCTION: Mediterranean diet (MeDiet) has been associated with lower risk of stroke. Additionally, animal models suggested that some components of MeDiet are associated with better outcomes after ischemic stroke (IS). We aimed to evaluate the association between global adherence to the MeDiet and the consumption of particular components of the MeDiet with stroke outcomes. MATERIAL AND METHODS: Multicenter observational study of consecutive IS patients treated with endovascular therapy. Inclusion criteria were large anterior circulation vessel occlusion and pre-stroke modified Rankin scale (mRS) <2. Adherence to MeDiet prior to stroke was evaluated using MEDAS 14-item scale. We evaluated the total score and also individual components of the scale. Clinical, radiological, and prognostic variables were collected. Good functional prognosis was considered as mRS ≤2 and complete recanalization as thrombolysis in cerebral infarction 3. RESULTS: From January 1 to October 30, 2018, 239 patients were included (mean age 71 years, 48% women, median baseline NIHSS 16). Median MEDAS scale was 8 points (7-10). Patients with a higher adherence to MeDiet had significantly lower total and LDL-cholesterol levels. Total adherence score was not associated with stroke outcomes. In multivariate analyses, consumption of olive oil as the principal source of fat was independently associated with good functional outcome at 3 months, OR 3.2 (1.1-10.1) and daily consumption of wine was independently associated with complete recanalization, OR 2.0 (1.1-3.8). CONCLUSIONS: Our study suggests that some components of MeDiet, such as olive oil and wine consumption, are related to better prognosis after stroke. More studies are needed to confirm these findings.
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Dieta Mediterránea , Procedimientos Endovasculares , Accidente Cerebrovascular/terapia , Trombectomía , Anciano , Anciano de 80 o más Años , Evaluación de la Discapacidad , Procedimientos Endovasculares/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Aceite de Oliva , Cooperación del Paciente , Estudios Prospectivos , España , Accidente Cerebrovascular/diagnóstico , Trombectomía/efectos adversos , Factores de Tiempo , Resultado del Tratamiento , VinoRESUMEN
Extra-ischaemic (remote) brain heamorrhages after thrombolysis for ischaemic stroke occur in less than 3 % of treated patients, but it worsens prognosis. Little attention has been paid to the location of the haematomas. Among 12 patients with remote brain haemorrhage after thrombolysis, we report three patients with haemorrhage in the cerebellar vermis (25 %), with poor outcome. Previous hypertensive vasculopathy is deemed to be the most plausible cause.
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Isquemia Encefálica/tratamiento farmacológico , Vermis Cerebeloso/patología , Fibrinolíticos/efectos adversos , Hemorragias Intracraneales/inducido químicamente , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/efectos adversos , Activador de Tejido Plasminógeno/efectos adversos , Anciano , Anciano de 80 o más Años , Isquemia Encefálica/diagnóstico por imagen , Isquemia Encefálica/patología , Vermis Cerebeloso/diagnóstico por imagen , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Hemorragias Intracraneales/diagnóstico por imagen , Hemorragias Intracraneales/patología , Masculino , Persona de Mediana Edad , Accidente Cerebrovascular/diagnóstico por imagen , Accidente Cerebrovascular/patología , Activador de Tejido Plasminógeno/uso terapéutico , Tomografía Computarizada por Rayos XRESUMEN
We report a patient with an important scenario that may arise in the management of an acute ischemic stroke: the need for a repeated mechanical thrombectomy in the same intracranial artery segment. The patient had a history of atrial fibrillation and a mechanical mitral valve replacement. In her first stroke, she had an occlusion of the proximal segment of the right middle cerebral artery; 58 days later, she presented with an occlusion in the same segment of that cerebral artery. In both instances, the thrombus was extracted by a stent retriever with good clinical and radiographic results. To the best of our knowledge, this is the first report of a repeated mechanical thrombectomy in the same intracranial artery segment using stent retriever devices.
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Infarto de la Arteria Cerebral Media/terapia , Trombectomía/métodos , Anticoagulantes/uso terapéutico , Fibrilación Atrial/complicaciones , Fibrilación Atrial/tratamiento farmacológico , Angiografía Cerebral/métodos , Angiografía por Tomografía Computarizada , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Infarto de la Arteria Cerebral Media/diagnóstico por imagen , Infarto de la Arteria Cerebral Media/etiología , Persona de Mediana Edad , Recurrencia , Retratamiento , Stents , Trombectomía/instrumentación , Resultado del TratamientoRESUMEN
Introduction: We aimed to evaluate if prior oral anticoagulation (OAC) and its type determines a greater risk of symptomatic hemorrhagic transformation in patients with acute ischemic stroke (AIS) subjected to mechanical thrombectomy. Materials and Methods: Consecutive patients with AIS included in the prospective reperfusion registry NORDICTUS, a network of tertiary stroke centers in Northern Spain, from January 2017 to December 2019 were included. Prior use of oral anticoagulants, baseline variables, and international normalized ratio (INR) on admission were recorded. Symptomatic intracranial hemorrhage (sICH) was the primary outcome measure. Secondary outcome was the relation between INR and sICH, and we evaluated mortality and functional outcome at 3 months by modified Rankin scale. We compared patients with and without previous OAC and also considered the type of oral anticoagulants. Results: About 1.455 AIS patients were included, of whom 274 (19%) were on OAC, 193 (70%) on vitamin K antagonists (VKA), and 81 (30%) on direct oral anticoagulants (DOACs). Anticoagulated patients were older and had more comorbidities. Eighty-one (5.6%) developed sICH, which was more frequent in the VKA group, but not in DOAC group. OAC with VKA emerged as a predictor of sICH in a multivariate regression model (OR, 1.89 [95% CI, 1.01-3.51], p = 0.04) and was not related to INR level on admission. Prior VKA use was not associated with worse outcome in the multivariate regression model nor with mortality at 3 months. Conclusions: OAC with VKA, but not with DOACs, was an independent predictor of sICH after mechanical thrombectomy. This excess risk was associated neither with INR value by the time thrombectomy was performed, nor with a worse functional outcome or mortality at 3 months.
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BACKGROUND AND PURPOSE: Spain has been one of the countries heavily stricken by COVID-19. But this epidemic has not affected all regions equally. We analyzed the impact of the COVID-19 pandemic on hospital stroke admissions and in-hospital mortality in tertiary referral hospitals from North-West Spain. METHODS: Spanish multicenter retrospective observational study based on data from tertiary hospitals of the NORDICTUS network. We recorded the number of patients admitted for ischemic stroke between 30 December 2019 and 3 May 2020, the number of IVT and EVT procedures, and in-hospital mortality. RESULTS: In the study period, 2737 patients were admitted with ischemic stroke. There was a decrease in the weekly mean admitted patients during the pandemic (124 vs. 173, p<0.001). In-hospital mortality of stroke patients increased significantly (9.9% vs. 6.5%, p = 0.003), but there were no differences in the proportion of IVT (17.3% vs. 16.1%, p = 0.405) or EVT (22% vs. 23%, p = 0.504). CONCLUSION: We found a decrease in the number of ischemic stroke admissions and an increase in in-hospital mortality during the COVID-19 epidemic in this large study from North-West Spain. There were regional changes within the network, not fully explained by the severity of the pandemic in different regions.