Quality of Life in Patients with Excellent 3-Month Clinical Outcome after First-Ever Ischemic Stroke: A Time to Redefine Excellent Outcome?

INTRODUCTION: Ischemic stroke (IS) may have impact on long-term health-related quality of life (HRQoL) even in the patients with good clinical outcome, and tools mostly used for the assessment of outcome may underestimate or not reflect all relevant sequels after IS. We aimed to analyze HRQoL in the patients with excellent outcome after IS. METHODS: We analyzed consecutive IS patients enrolled in the prospective FRAILTY study (ClinicalTrials.gov: NCT04839887) with excellent 3-month clinical outcome (score 0-1 in modified Rankin Scale [mRS]). Stroke Impact Scale (SIS) version 3.0 and Hospital Anxiety and Depression Scale (HADS) were used for the HRQoL, anxiety, and depression assessments, and subgroup comparisons were performed according to NIHSS score (0, ≥1), age (50<, ≥50 years), and sex. RESULTS: In total, 158 patients (55.7% men, mean age 60.3 ± 13.4 years) were analyzed, and 72.2% of them had score 0 in mRS. The overall lowest median scores were found in the SIS domain "emotion," "strength," and "participation." Patients with NIHSS ≥1 had lower scores in all SIS domains except "emotions" and "mobility." Patients ≥50 years had lower score in "mobility" (p = 0.004) and females in domain of "social participation" (p = 0.044). No differences were found among all subgroups in HADS anxiety and depression. Age, NIHSS score, and depression were found negative predictors for the physical domains of HRQoL. DISCUSSION/CONCLUSIONS: Despite excellent 3-month clinical outcome after IS, patients had affected substantially their HRQoL, especially those with NIHSS ≥1. Patients ≥50 years had more affected "mobility" and females "social participation."

Safety and Efficacy of Baseline Antiplatelet Treatment in Patients Undergoing Mechanical Thrombectomy for Ischemic Stroke: Antiplatelets Before Mechanical Thrombectomy.

PURPOSE: To investigate the safety and efficacy of baseline antiplatelet treatment in patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT). MATERIALS AND METHODS: Baseline use of antiplatelet medication before MT for (AIS) may provide benefit on reperfusion and clinical outcome but could also carry an increased risk of intracranial hemorrhage (ICH). All consecutive patients with AIS and treated with MT with and without intravenous thrombolysis (IVT) between January 2012 and December 2019 in all centers performing MT nationwide were reviewed. Data were prospectively collected in national registries (eg, SITS-TBY and RES-Q). Primary outcome was functional independence (modified Rankin Scale 0-2) at 3 months; secondary outcome was ICH. RESULTS: Of the 4,351 patients who underwent MT, 1,750 (40%) and 666 (15%) were excluded owing to missing data from the functional independence and ICH outcome cohorts, respectively. In the functional independence cohort (n = 2,601), 771 (30%) patients received antiplatelets before MT. Favorable outcome did not differ in any antiplatelet, aspirin, and clopidogrel groups when compared with that in the no-antiplatelet group: odds ratio (OR), 1.00 (95% CI, 0.84-1.20); OR, 1.05 (95% CI, 0.86-1.27); and OR, 0.88 (95% CI, 0.55-1.41), respectively. In the ICH cohort (n = 3,685), 1095 (30%) patients received antiplatelets before MT. The rates of ICH did not increase in any treatment options (any antiplatelet, aspirin, clopidogrel, and dual antiplatelet groups) when compared with those in the no-antiplatelet group: OR, 1.03 (95% CI, 0.87-1.21); OR, 0.99 (95% CI, 0.83-1.18); OR, 1.10 (95% CI, 0.82-1.47); and OR, 1.43 (95% CI, 0.87-2.33), respectively. CONCLUSIONS: Antiplatelet monotherapy before MT did not improve functional independence or increase the risk of ICH.

Factors affecting the quality of life after ischemic stroke in young adults: a scoping review.

PURPOSE: To synthesize the body of knowledge on the factors influencing the quality of life (QoL) after ischemic stroke (IS) in young adults. METHODS: Guidelines regarding the scoping review methodology developed by the Joanna Briggs Institute, and the PRISMA-ScR checklist for a scoping review was used in this paper. A total of 1197 studies were identified through a bibliographic search in Web of Science, MEDLINE, PsycInfo, ScienceDirect, Scopus, and ProQuest Science Database. Articles published between the years 2000-2021 were included. RESULTS: A total of nine papers were finally selected to respond to the research question. Three studies were prospective longitudinal studies compared QoL between young stroke and age-matched controls from the general population. Across all the analysed studies, 14 variables potentially associated with QoL were identified. QoL in young patients is mainly affected by clinical outcomes after IS (scored by the modified Rankin scale and the Barthel index-favourable initial functional status and higher independence in ADL leads to higher QoL) and psychological factors (post-stroke fatigue and depression-higher levels of fatigue and depression lead to lower QoL). The reviewed studies emphasized the importance of functional outcomes, post-stroke depression, fatigue and anxiety and early return to work. CONCLUSION: Further longitudinal studies are needed to identify the trajectory of post-stroke psychosocial symptoms over time and other potential predictors of unfavourable long-term QoL, thus specific young stroke rehabilitation and stroke self-management support programmes should be developed (address physical, psychological factors which influence the psychosocial adaptation post-stroke and the perception of the QoL).

Mechanical Thrombectomy Quality Indicators Study in Czech Stroke Centers: Results of the METRICS Study.

BACKGROUND AND PURPOSE: Rigorous and regular evaluation of defined quality indicators is crucial for further improvement of both technical and clinical results after mechanical thrombectomy (MT) for acute ischemic stroke (AIS). Following the recent international multi-society consensus quality indicators, we aimed to assess trend in these indicators on national level. MATERIAL AND METHODS: The prospective multicenter study (METRICS) was conducted in Czech Republic (CR) in year 2019. All participating centers collected technical and clinical data including defined quality indicators and results were subsequently compared with those from year 2016. RESULTS: In the 2019, 1375 MT were performed in the CR and 1178 (86%) patients (50.3% males, mean age 70.5 ± 13.0 years) were analyzed. Recanalization (TICI 2b-3) was achieved in 83.7% of patients and 46.2% of patients had good 3-month clinical outcome. Following time intervals were shortened in comparison to 2016: "hospital arrival - GP" (77 vs. 53 min; p<0.0001), "hospital arrival - maximal achieved recanalization" (122 vs. 93 min; p<0.0001), and "stroke onset - maximal achieved recanalization" (240 vs. 229 min; p p<0.0001). More patients with tandem occlusion were treated in 2019 (7.8 vs. 16.5%; p<0.0001) and more secondary transports were in 2019 (31.3 vs. 37.8%; p=0.002). No difference was found in 3-month clinical outcome and in the rate of periprocedural complications. Results of the METRICS study met all criteria of multi-society consensus quality indicators. CONCLUSION: Nationwide comparison between 2016 and 2019 showed improvement in the key time intervals, but without better overall clinical outcomes after MT.

Transport strategy for ischaemic stroke patients with large vessel occlusion.

INTRODUCTION: There are today two models of transporting patients with acute ischaemic stroke because of large artery occlusion (AIS-LVO): mothership (MS) and drip-and-ship (DS). Our aim was to evaluate our ongoing transport strategy (OT), which is an MS/DS hybrid. In our OT, the patient is transported directly to the CT of the Primary Stroke Centre (PSC), where intravenous thrombolysis (IVT) is administered. The patient then continues without delay to a Comprehensive Stroke Centre (CSC) with the same medical rescue team (MRT). The distance between our centres is 73 km. MATERIAL AND METHODS: We retrospectively analysed data of 100 consecutive AIS-LVO patients treated with mechanical thrombectomy (MT) between January 2017 and October 2019. OT, MS and DS groups were compared. 31 patients were transported as MS, 32 as DS, and 37 as OT. RESULTS: DS had significantly longer time to groin puncture (185 min) compared to OT and MS (p < 0.0001). OT shortened time almost to MS level (OT 124 min, MS 110 min, p = 0.002. Time to IVT administration (from MRT departure) differed statistically significantly in favour of OT (OT 27 min, MS 63 min, p < 0.0001). Logistical change in PSC had a significant effect on decreasing the door-to-needle time (DNT) median from 37 min to 11 min (p < 0.0001). DNT reduction also occurred in patients with AIS and without an indication for MT. CONCLUSIONS: OT is highly effective, significantly reducing the time to IVT administration, and combining all the benefits, while eliminating all the disadvantages, of DS and MS. The OT concept gives all indicated patients a chance for MT to be performed, and does not overload the performing centre.

Arterial Hypertension and Risk of Recurrent Event in Young Ischemic Stroke Patients.

INTRODUCTION: In young patients, the cause of ischemic stroke (IS) remains often cryptogenic despite presence of traditional vascular risk factors (VRFs). Since arterial hypertension (AH) is considered the most important one, we aimed to evaluate the impact of AH and blood pressure (BP) levels after discharge on risk of recurrent IS (RIS) in young patients. METHODS: The study set consisted of acute IS patients < 50 years of age enrolled in the prospective Heart and Ischemic STrOke Relationship studY registered on ClinicalTrials.gov (NCT01541163). Cause of IS was assessed according to the ASCOD classification. RESULTS: Out of 319 enrolled patients <50 years of age (179 males, mean age 41.1 ± 7.8 years), AH was present in 120 (37.6%) of them. No difference was found in the rates of etiological subtypes of IS between patients with and without AH. Patients with AH were older, had more VRF, used more frequently antiplatelets prior IS, and had more RIS (10 vs. 1%, p = 0.002) during a follow-up (FUP) with median of 25 months. Multivariate logistic regression stepwise model showed the prior use of antiplatelets as only predictor of RIS (p = 0.011, OR: 6.125; 95% CI: 1.510-24.837). Patients with elevated BP levels on BP Holter 1 month after discharge did not have increased rate of RIS during FUP (3.8 vs. 1.7%, p = 1.000). CONCLUSION: AH occurred in 37.6% of young IS patients. Patients with AH had more frequently RIS. Prior use of antiplatelets was found only predictor of RIS in young IS patients with AH.

Socioeconomic status and lifestyle in young ischaemic stroke patients: a possible relationship to stroke recovery and risk of recurrent event.

OBJECTIVES: Socioeconomic status (SES) and lifestyle have impact on recovery after ischaemic stroke (IS) and on risk of recurrent ischaemic stroke (RIS) in elderly patients. With regard to currently available limited data on young people, we aimed to assess SES and parameters of lifestyle and evaluate their relationship to stroke recovery and risk of RIS in young patients. METHODS: We analysed consecutive young IS patients < 50 years enrolled in the prospective HISTORY (Heart and Ischaemic STrOke Relationship studY) study registered on ClinicalTrials.gov (NCT01541163). Data were acquired from structured a self-evaluating multiple-choice questionnaire. Clinical outcome was assessed using the Modified Rankin Scale (MRS) after 3 months with score 0-1 for excellent outcome. RESULTS: Data were obtained from 297 (163 males, mean age 39.6 ± 7.8 years) young patients. Patients with MRS 0-1 (237, 79.8%) did not differ in SES except university education (21.1 vs. 3.3%; p = 0.001), less smoked (16.5 vs. 58.3%; p < 0.001), more of them did regular sport activities (79.1 vs. 51.6%; p = 0.02) and passed regular preventive medical checks (45.6 vs. 24.2%; p = 0.01). Twelve (4%) patients suffered from RIS during a follow-up with median of 25 months. They did not differ in SES but had higher body mass index (31.6 vs. 26.7; p = 0.007), reported less regular sport activities (16.7 vs. 73.0%; p < 0.001) and less regular medical checks (8.3 vs. 40.0%; p = 0.001). CONCLUSION: In young patients, SES had no relationship to clinical outcome after IS and to risk of RIS except education level. Some parameters of health lifestyle were presented more in patients with excellent outcome and without RIS during the follow-up.

Antithrombotic Treatment of Embolic Stroke of Undetermined Source: RE-SPECT ESUS Elderly and Renally Impaired Subgroups.

Background and Purpose- The RE-SPECT ESUS trial (Randomized, Double-Blind, Evaluation in Secondary Stroke Prevention Comparing the Efficacy and Safety of the Oral Thrombin Inhibitor Dabigatran Etexilate Versus Acetylsalicylic Acid in Patients With Embolic Stroke of Undetermined Source) tested the hypothesis that dabigatran would be superior to aspirin for the prevention of recurrent stroke in patients with embolic stroke of undetermined source. This exploratory subgroup analysis investigates the impact of age, renal function (both predefined), and dabigatran dose (post hoc) on the rates of recurrent stroke and major bleeding. Methods- RE-SPECT ESUS was a multicenter, randomized, double-blind trial of dabigatran 150 or 110 mg (for patients aged ≥75 years and/or with creatinine clearance 30 to <50 mL/minute) twice daily compared with aspirin 100 mg once daily. The primary outcome was recurrent stroke. Results- The trial, which enrolled 5390 patients from December 2014 to January 2018, did not demonstrate superiority of dabigatran versus aspirin for prevention of recurrent stroke in patients with embolic stroke of undetermined source. However, among the population qualifying for the lower dabigatran dose, the rate of recurrent stroke was reduced with dabigatran versus aspirin (7.4% versus 13.0%; hazard ratio, 0.57 [95% CI, 0.39-0.82]; interaction P=0.01). This was driven mainly by the subgroup aged ≥75 years (7.8% versus 12.4%; hazard ratio, 0.63 [95% CI, 0.43-0.94]; interaction P=0.10). Stroke rates tended to be lower with dabigatran versus aspirin with declining renal function. Risks for major bleeding were similar between treatments, irrespective of renal function, but with a trend for lower bleeding rates with dabigatran versus aspirin in older patients. Conclusions- In subgroup analyses of RE-SPECT ESUS, dabigatran reduced the rate of recurrent stroke compared with aspirin in patients qualifying for the lower dose of dabigatran. These results are hypothesis-generating. Aspirin remains the standard antithrombotic treatment for patients with embolic stroke of undetermined source. Registration- URL: https://www.clinicaltrials.gov; Unique identifier: NCT02239120.

Young cryptogenic ischemic stroke: A descriptive analysis of clinical and laboratory characteristics, outcomes and stroke recurrence.

BACKGROUND AND PURPOSE: Ischemic strokes (IS) occur also in young adults and despite an extensive work-up the cause of IS remains very often cryptogenic. Thus, effectiveness of secondary prevention may be unclear. We aimed to analyze a relationship among vascular risk factors (VRF), clinical and laboratory parameters, outcomes and recurrent IS (RIS) in young cryptogenic IS (CIS) patients. SUBJECTS AND METHODS: The study set consisted of young acute IS patients < 50 years enrolled in the prospective HISTORY (Heart and Ischemic STrOke Relationship studY) study registered on ClinicalTrials.gov (NCT01541163). All analyzed patients underwent transesophageal echocardiography, 24-h and 3-week ECG-Holter to assess cause of IS according to the ASCOD classification. Recurrent IS (RIS) was recorded during a follow-up (FUP). RESULTS: Out of 294 young enrolled patients, 208 (70.7%, 113 males, mean age 41.6 ± 7.2 years) were identified as cryptogenic. Hyperlipidemia (43.3%), smoking (40.6%) and arterial hypertension (37.0%) were the most frequent VRF. RIS occurred in 7 (3.4%) patients during a mean time of FUP 19 ± 23 months. One-year risk of RIS was 3.4% (95%CI: 1.4-6.8%). Patients with RIS were older (47.4 vs. 41.1 years, p = 0.007) and more often obese (71.4 vs. 19.7%, p = 0.006), and did not differ in any of other analyzed parameters and VRF. Multivariate logistic regression analysis showed obesity (OR: 9.527; 95%CI: 1.777-51.1) and the previous use of antiplatelets (OR: 15.68; 95%CI: 2.430-101.2) as predictors of recurrent IS. CONCLUSION: Despite a higher presence of VRF in young CIS patients, the risk of RIS was very low. Obesity and previous use of antiplatelet therapy were found the only predictors of RIS.

Low Levels of Glycemia within the First 48 Hours after Mechanical Thrombectomy for Acute Ischemic Stroke May be Associated with Better Clinical Outcome.

INTRODUCTION: Many different factors may have an impact on clinical outcome after mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We aimed to investigate levels of serum glycemia (GLY) within the first 48 hours after MT. SUBJECTS AND METHODS: Consecutive AIS patients were enrolled in the retrospective bi-center study. Neurological deficit was assessed with National Institutes of Health Stroke Scale (NIHSS) and functional outcome after 3 months with modified Rankin scale with a score 0-2 for good outcome. Presence of symptomatic intracerebral hemorrhage was assessed according to the SITS- MOST criteria. RESULTS: In total, 868 patients (442 males, mean age 69.7 ± 12.2 years) with a median of admission NIHSS 17 points were enrolled in the study and 253 (29.1%) of them were diabetics. Recanalization was reached in 758 (87.3%) patients. Patients with good outcome (412, 47.5%) had lower median of GLY (6.5 versus 7.4 mmol/L, P < .0001) within the first 48 hours after MT. Similar results were found also in diabetics (8.1 versus 9.6 mmol/L, P < .0001) and in patients with achieved recanalization (6.5 versus 7.5 mmol/L, P < .0001). Multivariate regression analysis with adjustment for potential confounders showed median of GLY (P = .0001, odds ratio: 0.830, 95% confidence interval: 0.755-0.913) as a predictor of good outcome after MT. CONCLUSION: Lower levels of GLY within the first 48 hours after MT may be associated with better functional outcome after 3 months.

Patent Foramen Ovale and the Risk of Cerebral Infarcts in Acute Pulmonary Embolism-A Prospective Observational Study.

BACKGROUND: Pulmonary embolism (PE) is associated with a risk of consecutive paradoxical embolism with brain infarction through a patent foramen ovale (PFO). The aims of this study were to assess the rate of new ischemic brain lesions (IBLs) using magnetic resonance imaging (MRI) during a 12-month follow-up period with anticoagulation and to evaluate the potential relationship with the presence of PFO on transesophageal echocardiography (TEE). SUBJECTS AND METHODS: Seventy-eight patients with acute PE underwent baseline contrast TEE with brain MRI. After the 12-month follow-up, 58 underwent brain MRI. The rates of MRI documenting new IBLs were measured based on the presence of PFO. RESULTS: PFO was detected in 31 patients (39.7%). At baseline MRI, IBL was present in 39 of 78 patients (50%). The presence of IBL was not significantly higher in patients with PFO than in patients without PFO (20 [64.5% patients with PFO] versus 19 [40.4% without PFO] of 39 patients with baseline IBL, P = .063). At the follow-up MRI, in the group with new IBL (9 of 58 patients, 15.5%), the number of patients with PFO was significantly higher than that without PFO (7 [33.3%] versus 2 [5.4%], P = .008). PFO was identified as an independent predictor of new IBL (odds ratio 4.6 [1.6-47.4], P = .008). CONCLUSIONS: The presence of PFO was associated with new IBL in patients with PE. These patients are at a higher risk of ischemic stroke despite effective anticoagulation therapy.

Intravenous Thrombolysis in Patients with Acute Ischemic Stroke after a Reversal of Dabigatran Anticoagulation with Idarucizumab: A Real-World Clinical Experience.

BACKGROUND: Intravenous thrombolysis (IVT) is contraindicated in patients with acute ischemic stroke (AIS) using oral anticoagulants. A specific human monoclonal antibody was introduced to reverse immediately the anticoagulation effect of the direct inhibitor of thrombin, dabigatran. Until now, mostly individual cases presenting with successful IVT after a reversal of dabigatran anticoagulation in patients with AIS were published. Thus, we aimed to report real-world data from clinical practice. METHODS: Patients with AIS on dabigatran treated with IVT after antidote reversal were enrolled in the retrospective nationwide study. Neurological deficit was scored using the National Institutes of Health Stroke Scale (NIHSS) and 90-day clinical outcome using modified Rankin scale (mRS) with a score 0-2 for a good outcome. Intracerebral hemorrhage (ICH) was defined as a presence of any sign of bleeding on control imaging after IVT, and symptomatic intracerebral hemorrhage (SICH) was assessed according to the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) criteria. RESULTS: In total, 13 patients (7 men, mean age 70.0 ± 9.1 years) with a median NIHSS admission score of 7 points were analyzed. Of these patients, 61.5% used 2 × 150 mg of dabigatran daily. Antidote was administrated 427 ± 235 minutes after the last intake of dabigatran, with a mean activated prothrombin time of 38.1 ± 27.8 seconds and a mean thrombin time of 72.2 ± 56.1 seconds. Of the 13 patients, 2 had ICH and 1 had SICH, and no other bleeding complications were observed after IVT. Of the total number of patients, 76.9% had a good 3-month clinical outcome and 3 patients (23.1%) died. Recurrent ischemic stroke occurred in 2 patients (15.4%). CONCLUSION: The data presented in the study support the safety and efficacy of IVT after the reversal of the anticoagulation effect of dabigatran with antidote in a real-world clinical practice.

Atrial fibrillation in young ischemic stroke patients: an underestimated cause?

BACKGROUND: Undetected atrial fibrillation (AF) is often suspected as the possible cause in patients with cryptogenic ischemic stroke (IS), especially in elderly population. In young IS patients, the prevalence of AF, particularly paroxysmal form, remains still not enough established. Our aim was to assess the presence of AF in young patients using a long-term electrocardiography (ECG) Holter monitoring. METHODS: The study set consisted of acute IS patients ≤50 years enrolled in the prospective HISTORY (Heart and Ischemic STrOke Relationship studY) study (NCT01541163). In all patients, admission ECG, serum cardiac markers, transesophageal echocardiography, 24-h and 3-week ECG Holter monitoring were performed. RESULTS: Out of 634 enrolled patients in the HISTORY study, 98 were ≤50 years (56 males, mean age 39.7 ± 8.4). In total, AF was detected in 10.2% of patients and 70% of them had a paroxysmal form of AF. The elevated serum cardiac markers were present in 70% of patients with detected AF (p = 0.0001). CONCLUSION: AF was detected in 10.2% of young stroke patients and paroxysmal form of AF prevailed. Using of long-term ECG Holter monitoring improved the detection of AF. Patients with presence of AF had more frequently elevated serum specific cardiac markers.

Outcome predictors in acute basilar artery occlusion.

OBJECTIVE: to identify predictors of good outcome in acute basilar artery occlusion (Bao). Background: acute ischemic stroke (aiS) caused by Bao is often associated with a severe and persistent neurological deficit and a high mortality rate. METHODS: the set consisted of 70 consecutive aiS patients (51 males; mean age 64.5 ± 14.5 years) with Bao. the role of the following factors was assessed: baseline characteristics, stroke risk factors, pre-event antithrombotic treatment, neurological deficit at time of treatment, estimated time to therapy procedure initiation, treatment method, recanalization rate, change in neurological deficit, post-treatment imaging findings. 30- and 90-day outcome was assessed using the modified rankin scale with a good outcome defined as a score of 0­ 3. RESULTS: the following statistically significant differences were found between patients with good versus poor outcomes: mean age (54.2 vs. 68.9 years; p=0.0001), presence of arterial hypertension (52.4% vs. 83.7%; p=0.015), diabetes mellitus (9.5% vs. 55.1%; p=0.0004) and severe stroke (14.3% vs. 65.3%; p=0.0002), neurological deficit at time of treatment (14.0 vs. 24.0 median of national institutes of health Stroke Scale [nihSS] points; p=0.001), successful recanalization (90.0% vs. 54.2%; p=0.005), change in neurological deficit (12.0 vs. 1.0 median difference of nihSS points; p=0.005). Stepwise binary logistic regression analysis identified age (or=0.932, 95% Ci=0.882­0.984; p=0.012), presence of diabetes mellitus (or=0.105, 95% Ci=0.018-0.618; p=0.013) and severe stroke (or=0.071, 95% Ci=0.013-0.383; p=0.002) as significant independent negative predictors of good outcome. CONCLUSIONS: in the present study, higher age, presence of diabetes mellitus and severe stroke were identified as significant independent negative predictors of good outcome.

[Embolic ischemic strokes]. / Embolizacní ischemické cévní mozkové príhody.

Treatment of acute phase of ischemic stroke is aimed to limit the amount of damage using reperfusion strategy and subsequently administration of treatment providing pharmacological secondary prevention of recurrence. The early aetiology diagnosis of stroke is crucial for effective secondary prevention as the highest risk of recurrence is within few weeks after stroke. Exclusion of cardiac and vascular source of embolism by imaging methods is an important part in management of patients with ischemic stroke. These embolic sources are categorized as high risk and states are associated with moderate or unclear risk.

Study protocol - Prospective case-control trial - Impact of significant carotid stenosis on retinal perfusion measured with automated retinal oximetry.

BACKGROUND: Large vessel carotid stenosis is a significant cause of ischaemic stroke. Indications for surgical revascularisation depend on the severity of the stenosis and clinical symptoms. However, mild symptoms such as TIA (Transient ischaemic attack), amaurosis fugax or minor stroke precede large strokes in only 15% of cases. AIM: The aim of this prospective study is to evaluate whether retinal perfusion is impacted in significant carotid stenosis. Automated retinal oximetry will be used to better assess perfusion in the post-stenotic basin. We presume the more stenotic the blood vessel, the more reduced the retinal perfusion is, resulting in adaptive changes such as greater arteriovenous saturation difference due to greater oxygen extraction. This could broaden the indication spectrum for revascularisation for carotid stenosis. METHODS: We plan to enroll yearly 50 patients with significant carotid stenosis and cross-examine them with retinal oximetry. The study group will provide stenotic vessels and, non-stenotic vessels will form the control group. Patients with significant carotid stenosis will undergo an MRI (Magnetic Resonnance imaging) examination to determine the presence of asymptomatic recent ischaemic lesions in the stenotic basin, and the correlation to oximetry parameters. STATISTICS: The stenosis severity and retinal oximetry parameters will be compared for study and control groups with a threshold of 70%, respectively 80% and 90% stenosis. Results will be then reevaluated with emphasis on MRI findings in the carotid basin. CONCLUSION: This prospective case control study protocol will be used to launch a multicentre trial assessing the relationship between significant carotid stenosis and retinal perfusion measured with automated retinal oximetry. Despite these differences, the findings indicate the potential of retinal oximetry for noninvasive real-time measurements of oxyhaemoglobin saturation in central nervous system vessels. Following calibration upgrade and technological improvement, verification retinal oximetry may potentially be applied to critically ill and anaesthesia care patients. The study on combined scanning laser ophthalmoscope and retinal oximetry supports the feasibility of the technique for oximetry analysis in newly born babies. TRIAL REGISTRATION: ClinicalTrials.gov, ID: NCT06085612.

Predictors of Good Clinical Outcome After Endovascular Treatment for Acute Ischemic Stroke due to Tandem Lesion in Anterior Circulation: Results from the ASCENT Study.

PURPOSE: Endovascular treatment (EVT) of tandem lesion (TL) in anterior circulation (AC) acute ischemic stroke (AIS) represents still a clinical challenge. We aimed to evaluate selected factors related to EVT and assess other possible predictors of good clinical outcome besides the generally known ones. METHODS: AIS patients with TL in AC treated with EVT were enrolled in the multicenter retrospective ASCENT study. A good three-month clinical outcome was scored as 0-2 points in modified Rankin Scale (mRS) and achieved recanalization using the TICI scale. Symptomatic intracerebral hemorrhage (SICH) was assessed using the SITS-MOST criteria. Logistic regression analysis was used for the assessment of possible predictors of mRS 0-2 with adjustment for potential confounders. RESULTS: In total, 300 (68.7% males, mean age 67.3 ± 10.2 years) patients with median of admission NIHSS 17 were analyzed. Recanalization (TICI 2b-3) was achieved in 290 (96.7%) patients and 176 (58.7%) had mRS 0-2. Besides the age, admission NIHSS and SICH, admission glycemia (p = 0.005, OR: 0.884) the stent patency within the first 30 days after EVT (p = 0.0003, OR: 0.219), dual antiplatelet therapy (DAPT) started within 12 h after EVT (p < 0.0001, OR: 5.006) and statin therapy started within 24 h after stenting (p < 0.0001, OR: 5.558) were found as other predictors. CONCLUSION: Admission glycemia, start of DAPT within 12 h and statin therapy within 24 h after EVT, and stent patency within the first 30 days after EVT were found as other predictors of good three-month clinical outcome in AIS patients treated with EVT for TL.

Intravenous Thrombolysis in Posterior versus Anterior Circulation Stroke: Clinical Outcome Differs Only in Patients with Large Vessel Occlusion.

The safety and efficacy of intravenous thrombolysis (IVT) are well established in anterior circulation stroke (ACS) but are much less clear for posterior circulation stroke (PCS). The aim of this study was to evaluate the occurrence of parenchymal hematoma (PH) and 3-month clinical outcomes after IVT in PCS and ACS. In an observational, cohort multicenter study, we analyzed data from ischemic stroke patients treated with IVT prospectively collected in the SITS (Safe Implementation of Treatments in Stroke) registry in the Czech Republic between 2004 and 2018. Out of 10,211 patients, 1166 (11.4%) had PCS, and 9045 (88.6%) ACS. PH was less frequent in PCS versus ACS patients: 3.6 vs. 5.9%, odds ratio (OR) = 0.594 in the whole set, 4.4 vs. 7.8%, OR = 0.543 in those with large vessel occlusion (LVO), and 2.2 vs. 4.7%, OR = 0.463 in those without LVO. At 3 months, PCS patients compared with ACS patients achieved more frequently excellent clinical outcomes (modified Rankin scale [mRS] 0-1: 55.5 vs. 47.6%, OR = 1.371 in the whole set and 49.2 vs. 37.6%, OR = 1.307 in those with LVO), good clinical outcomes (mRS 0-2: 69.9 vs. 62.8%, OR = 1.377 in the whole set and 64.5 vs. 50.5%, OR = 1.279 in those with LVO), and had lower mortality (12.4 vs. 16.6%, OR = 0.716 in the whole set and 18.4 vs. 25.5%, OR = 0.723 in those with LVO) (p < 0.05 in all cases). In PCS versus ACS patients, an extensive analysis showed a lower risk of PH both in patients with and without LVO, more frequent excellent and good clinical outcomes, and lower mortality 3 months after IVT in patients with LVO.

A controlled trial of revascularization in acute stroke.

PURPOSE: To compare safety and utility of intraarterial revascularization with use of stents to no revascularization in patients who either failed to respond to intravenous thrombolysis (IVT) or have contraindications to IVT. MATERIALS AND METHODS: The case-control study was approved by local ethics committees; all patients signed informed consent. One hundred thirty-one patients (74 men; mean age, 65.9 years ± 12.3; range, 25-86 years) with acute ischemic stroke (AIS) due to middle cerebral artery (MCA) occlusion were enrolled; 75 underwent IVT. No further recanalization therapy was performed in 26 (35%) IVT-treated patients with MCA recanalization (group 1). Patients with IVT failure after 60 minutes were allocated to endovascular treatment (group 2A) or no further therapy (group 2B). Patients with contraindication to IVT were allocated to endovascular treatment within 8 hours since AIS onset (group 3A) or to no recanalization therapy (group 3B). Neurologic deficit at admission, MCA recanalization, symptomatic intracerebral hemorrhage (SICH), and 3-month clinical outcome were evaluated. Favorable clinical outcome was defined as modified Rankin scale score 0-2 at 3 months after stroke onset. Two-sided Mann-Whitney U test, independent samples t test, Fisher exact test, multivariate logistic regression analysis of baseline variables, and complete MCA recanalization for the prediction of favorable clinical outcome were used for statistical evaluation. RESULTS: Median National Institutes of Health Stroke Scale score at admission was 13.5, 16.0, 15.5, 15.0, and 16.0 in groups 1, 2A, 2B, 3A, and 3B, respectively (P > .05); SICH occurred in one of 26 (3.8%), one of 23 (4.3%), one of 26 (3.8%), one of 31 (3.2%), and one of 25 (4.0%) patients, respectively (P > .05). MCA recanalization after endovascular treatment was achieved in 50 of 54 (92.6%) patients. Favorable outcome was significantly different between groups 2A and 2B (10 of 23 [43.5%] and four of 26 [15.4%], respectively; P = .03) and groups 3A and 3B (14 of 31 [45.2%] and two of 25 [8.0%], respectively; P = .004) and was dependent on MCA recanalization (odds ratio, 5.55; P = .006). CONCLUSION: In this controlled trial, intraarterial revascularization with stents was an effective and safe-effective treatment option in patients with acute MCA occlusion with contraindication to IVT or after IVT failure.

Acute combined revascularization in acute ischemic stroke with intracranial arterial occlusion: self-expanding solitaire stent during intravenous thrombolysis.

PURPOSE: To investigate the safety and efficacy of the self-expanding Solitaire stent used during intravenous thrombolysis (IVT) for intracranial arterial occlusion (IAO) in acute ischemic stroke (AIS). MATERIALS AND METHODS: Consecutive nonselected patients with AIS with IAO documented on computed tomographic angiography or magnetic resonance angiography and treated with IVT were included in this prospective study. Stent intervention was initiated and performed during administration of IVT without waiting for any clinical or radiologic signs of potential recanalization. Stroke severity was assessed by National Institutes of Health Stroke Scale (NIHSS), and 90-day clinical outcome was assessed by modified Rankin scale (mRS), with a good outcome defined as an mRS score of 0-2. Recanalization was rated by thrombolysis in cerebral infarction (TICI) scale. RESULTS: Fifty patients (mean age, 66.8 y ± 14.6) had a baseline median NIHSS score of 18.0. Overall recanalization was achieved in 94% of patients, and complete recanalization (ie, TICI 3 flow) was achieved in 72% of patients. The mean time from stroke onset to maximal recanalization was 244.2 minutes ± 87.9, with a median of 232.5 minutes. The average number of device passes was 1.5, with a mean procedure time to maximal recanalization of 49.5 minutes ± 13.0. Symptomatic intracerebral hemorrhage occurred in 6% of patients. The median mRS score at 90 days was 1, and 60% of patients had a good outcome (ie, mRS score 0-2). The overall 3-month mortality rate was 14%. CONCLUSIONS: Combined revascularization with the Solitaire stent during IVT appears to be safe and effective in the treatment of acute IAO.