Neurologist-Led Management of Implantable Loop-Recorders After Embolic Stroke of Undetermined Source.

INTRODUCTION: Upon completion of the workup for stroke, etiology cannot be identified in approximately one-third of the patients, with an embolic stroke of undetermined source (ESUS) accounting for around 50% of these cryptogenic etiologies. Whether management of complex long-term monitoring in order to detect suspected atrial fibrillation (AFib) could be initiated and managed through a neurologist is not sufficiently investigated. PATIENTS AND METHODS: We recruited all consecutive patients with ESUS who received implantation after neurological adjudication of Reveal LINQ® loop recorder between January 2016 and July 2020. We collected demographic, clinical, heart- and neuroimaging, laboratory, and electrocardiographic data assessed on prolonged baseline ECG monitoring, number of supraventricular (SVEs) and ventricular (VEs) extrasystolic complexes, and from preimplantation ECG-PQ interval. AFib detection was manually supervised and determined positive when the duration was over 120 s. RESULTS: We followed a total of 131 patients for a median of 504 days. There were 45 (34%) manually verified AFib diagnoses. In univariate analysis, earlier implantation after ESUS was associated with AFib detection (13 vs. 31 days, p = 0.011). In multivariate analysis, increased rate of AFib was associated with a more prolonged PQ interval (per 50-ms increase) (HR 1.99, 95% CI 1.39-2.85) and number of SVEs (HR 1.29, 95% CI 1.05-1.57) measured on pre-implantation ECG. CONCLUSION: We observed similar predictors for Afib after ESUS, albeit with higher frequency than previously reported. This study suggests that the neurologist-led decision, management, and evaluation of ILR after ESUS is feasible.

Follow-up after carotid stenting with the CASPER stent system: A duplex ultrasound evaluation.

OBJECTIVE: To report results of duplex ultrasound evaluation of consecutive patients after carotid stenting with the double layer Carotid Artery Stent designed to Prevent Embolic Release (CASPER) stent system. METHODS: Between January 2014 and June 2017, a single-center, retrospective study of 101 consecutive patients (21.8% female; median age, 72.1 years) was performed. Patients with internal carotid artery stenosis treated with the CASPER stent were included. Eligibility criteria for stenting included stenosis of ≥70% of the vessel diameter (or ≥50% diameter with ulceration) in symptomatic carotid artery stenosis or ≥80% stenosis in asymptomatic patients at the carotid artery bifurcation or the proximal cervical internal carotid artery. Duplex ultrasound examination was performed before and within 24 hours of implantation as well as at 14 days, and 3, 6, and 12 months. RESULTS: At the 12-month follow-up visit, moderate in-stent restenosis (ISR) (≥50% and <70%) was detected in three stents (2.8%) and severe (≥70%) ISR in two (1.9%; including one case of stent occlusion). All but the two latter patients remained asymptomatic during the follow-up period. One patient required retreatment for ISR after a minor stroke and another patient with stent occlusion also re-presented with a minor stroke. Multivariable logistic regression was unable to detect any significant factors associated with ISR. CONCLUSIONS: Duplex ultrasound examination after carotid stenting is a useful tool for patient follow-up and determination of ISR. We found a low incidence of ISR assessed by duplex ultrasound examination at 12 months after CASPER stenting, but further studies are warranted.

Endovascular Therapy for Tandem Occlusion in Acute Ischemic Stroke: Intravenous Thrombolysis Improves Outcomes.

Ischemic stroke related to tandem internal carotid and middle cerebral artery (TIM) occlusion is a challenging condition where endovascular treatment (EVT) is an emerging revascularization option. The identification of factors influencing clinical outcomes can assist in creating appropriate therapeutic algorithms for such patients. This study aimed to evaluate prognostic factors in the context of EVT for TIM occlusion. We performed a retrospective study of consecutive patients with TIM occlusion admitted within 6 h from symptom onset to two tertiary stroke centers. We recorded the etiology of stroke, clinical deficits at stroke onset and discharge, details of EVT, final infarct volume (FIV), in-hospital mortality, and outcome at three months. Among 73 patients with TIM occlusion, 53 were treated with EVT. The median age was 75.9 years (interquartile range (IQR) 64.6⁻82.6), with the most common etiology of cardioembolism (51.9%). Intravenous thrombolysis with tissue-plasminogen activator (t-PA) was performed in the majority (69.8%) of cases. EVT achieved successful recanalization with a thrombolysis in cerebral infarction (TICI) grade of 2b or 3 in 67.9%. A good outcome (modified Rankin score of 0⁻2 at three months) was observed in 37.7%. After adjustment for age, the National Institutes of Health Stroke Scale (NIHSS) at admission, and success of recanalization, smaller final infarct volume (odds ratio (OR) 0.021 for FIV above 25th percentile (95% CI 0.001⁻0.332, p = 0.005)) and administration of intravenous t-PA (OR 12.04 (95% CI 1.004⁻144.392, p = 0.049)) were associated with a good outcome at three months. Our study demonstrates that bridging with t-PA is associated with improved outcomes in the setting of tandem ICA and MCA occlusions treated with EVT and should therefore not be withheld in eligible patients.

Influence of the circle of Willis on leptomeningeal collateral flow in anterior circulation occlusive stroke: Friend or foe?

BACKGROUND: Clinical outcome after large vessel occlusion (LVO) stroke depends on collateral integrity. We aimed to evaluate whether the completeness of the circle of Willis (CoW) and anterior temporal artery (ATA) determines the status of leptomeningeal collaterals (LC) in patients with acute LVO (internal carotid artery (ICA) and middle cerebral artery M1 (MCA) occlusion) treated with endovascular thrombectomy. PATIENTS AND METHODS: LC, cross-flow through the anterior communicating artery (ACoA), presence of the ipsilateral posterior communicating artery (IpsiPCoA) and presence of the ATA were evaluated using CT angiography. LC was graded as good when ≥50% collateral filling was noted compared to the unaffected hemisphere. RESULTS: We included 159 patients with a median age of 75 years (IQR 63-82), MCA M1 occlusion in 96 (60%) and good outcome in 68 (45.6%). The LC were good in 129 (81.1%) patients. Complete IpsiPCoA and incomplete ACoA status was inversely associated with good LC in LVO (OR 0.51 (95% CI 0.02-0.07)). A complete CoW was associated with good LC in ICA occlusions, OR 8.4 (p = .025). Good outcome (modified Rankin scale 0-2 at 3 months) was associated with good LC (OR 5.63 (95% CI 1.11-28.4)), small ischemic lesion volume (OR 0.94 (95% CI 0.97-0.98)) and absence of the ACoA and IpsiPCoA (OR 4.47 (95% CI 1.09-18.3)). CONCLUSIONS: ATA presence was associated with good leptomeningeal collaterals in LVO (OR 8.13 (95% CI 1.69-39.0)) and in MCA M1 patients (OR 7.9 (95% CI 1.7-36.4)). The effect of ATA was most pronounced in MCA M1 occlusions, and that of ACoA was most pronounced in ICA occlusions.

Higher Blood Pressure during Endovascular Thrombectomy in Anterior Circulation Stroke Is Associated with Better Outcomes.

BACKGROUND AND PURPOSE: Reports investigating the relationship between in-procedure blood pressure (BP) and outcomes in patients undergoing endovascular thrombectomy (EVT) due to anterior circulation stroke are sparse and contradictory. METHODS: Consecutive EVT-treated adults (modern stent retrievers, BP managed in line with the recommendations, general anesthesia, invasive BP measurements) were evaluated for associations of the rate of in-procedure systolic BP (SBP) and mean arterial pressure (MAP) excursions to >120%/<80% of the reference values (serial measurements at anesthesia induction) and of the reference BP/weighted in-procedure mean BP with post-procedure imaging outcomes (ischemic lesion volume [ILV], hemorrhages) and 3-month functional outcome (modified Rankin Scale [mRS], score 0 to 2 vs. 3 to 6). RESULTS: Overall 164 patients (70.7% pharmacological reperfusion, 80.5% with good collaterals, 73.8% with successful reperfusion) were evaluated for ILV (range, 0 to 581 cm3) and hemorrhages (incidence 17.7%). Higher rate of in-procedure SBP/MAP excursions to >120% was independently associated with lower ILV, while higher in-procedure mean SBP/MAP was associated with lower odds of hemorrhages. mRS 0-2 was achieved in 75/155 (48.4%) evaluated patients (nine had missing mRS data). Higher rate of SBP/MAP excursions to >120% and higher reference SBP/MAP were independently associated with higher odds of mRS 0-2, while higher ILV was associated with lower odds of mRS 0-2. Rate of SBP/MAP excursions to <80% was not associated with any outcome. CONCLUSION: s In the EVT-treated patients with BP managed within the recommended limits, a better functional outcome might be achieved by targeting in-procedure BP that exceeds the preprocedure values by more than 20%.

Sigmoid Sinus Characteristics Correlate with Early Clinical and Imaging Surrogates in Anterior Circulation Ischemic Stroke.

Cerebral venous outflow may play a decisive role in acute ischemic stroke. Here, we assessed the relation of cerebral sinus vein characteristics with clinical and imaging surrogates of early outcome in acute ischemic stroke. We evaluated cerebral vein characteristics in 212 patients with the middle cerebral artery (MCA) occlusive stroke confirmed by CT angiography CTA within 6 h from symptom onset. Readout parameters included volume and density of the sigmoid sinus (SS) and density of the superior sagittal sinus (SupSagS). These were correlated with early clinical outcome defined as hospital death (HD), final infarct volume (FIV), and National Institute of Health Stroke Scale (NIHSS) at discharge. We found a correlation for the volume of the right SS and the FIV when the M1 segment of the MCA of either side was occluded (p = 0.002, Rho = 0.206, n = 134). A decrease in SS density was more pronounced in the subgroup with unfavorable outcome (NIHSS > 15 + HD) but only when the left hemisphere was affected (p = 0.026, n = 101). On stepwise logistic regression analysis, adjusted for on-admission NIHSS, age at presentation, and FIV, smaller SS volume was independently associated with lower odds for hospital death (n = 183, OR 0.13, 95 % CI 0.02-0.94, p = 0.043). A larger right SS and a decrease in density increase the risk of unfavorable early clinical and imaging outcome in AIS. This finding of an outflow pattern independent of the stroke site implicates an involvement of the cerebral venous drainage system in the pathophysiology of ischemic stroke.