The detrimental impact of silent cerebral infarcts on asymptomatic carotid endarterectomy outcome.

BACKGROUND: Silent cerebral infarctions (SCIs) can be identified by preoperative computed tomography (CT) scans in patients with severe carotid stenosis being considered for carotid endarterectomy (CEA). It is unknown whether this finding has any effect on perioperative complications or long-term outcome. This study investigates the influence of SCI on early and late complications in asymptomatic patients undergoing CEA. METHODS: All consecutive CEAs undertaken for asymptomatic severe carotid stenosis from 2005 to 2013 were retrospectively evaluated for clinical and anatomic characteristics. SCI was defined as cerebral embolic infarcts in the anterior or middle cerebral artery territory, ipsilateral to the target carotid stenosis, identified on preoperative CT. The end points of the study were to compare the 30-day and long-term stroke and death rate after CEA in patients with and without SCI. All patients were followed yearly through duplex ultrasonography and clinical assessment. Statistical methods used were Cox regression (hazard ratio) and Kaplan-Meier for life-table analysis. RESULTS: A total of 743 CEAs were performed in asymptomatic patients during the study period of which all had CT scans, and 97 (13.1%) demonstrated SCI. All patient stroke and death outcomes at 30 days were 0.5% and 0.7%, respectively. Patients with SCI had a significantly higher 30-day stroke outcome (3.1% vs 0.2%; P = .001; odds ratio, 16.39; 95% confidence interval, 1.33-201.4; P = .02) but not death or stroke/death outcome (0% vs 0.8%; P = .19 and 3.1% vs 0.9%, P = .06, respectively) compared with those without SCI. In addition, at a mean follow-up of 44.3 ± 23.9 months, the patients with SCI had a significantly worse 5-year ipsilateral stroke or any stroke-/death-free survival compared with patients without SCI (86.7% vs 99.0%; P = .001; and 76.9% vs 87.7%; P = .004). SCI was confirmed as an independent predictor of late any stroke/death by Cox regression (hazard ratio, 2.45; 95% confidence interval, 1.29-4.67; P = .006). CONCLUSIONS: Patients who have SCI in the presence of severe carotid stenosis and undergo CEA have significantly worse perioperative stroke and long-term stroke/death outcomes. This data would suggest that asymptomatic patients undergoing CEA who have CT scan evidence of a cerebral infarct have worse prognosis than those with normal CT scans.

Outcomes Are Not Different between Patients with Intermediate and High DWI-ASPECTS after Stent-Retriever Embolectomy for Acute Anterior Circulation Stroke.

BACKGROUND AND PURPOSE: Questions remain as to what benefits embolectomy provides to patients presented with considerable early ischemic changes on baseline imaging studies. This study aimed to investigate the impact of the Alberta Stroke Program Early CT Score applied to DWI on treatment outcomes in patients with acute stroke undergoing stent-retriever embolectomy. MATERIALS AND METHODS: We retrospectively analyzed the clinical and DWI data from 171 patients with acute anterior circulation stroke who were treated with stent-retriever embolectomy within 6 hours of symptom onset. DWI-ASPECTS scores were analyzed with the full scale or were dichotomized (4-6 versus 7-10). Patients with DWI-ASPECTS ≤3 were excluded from the study. Associations between outcome and clinical and radiologic factors were determined with a multivariate logistic regression analysis. A good outcome was defined as a modified Rankin Scale score of 0-2 at 3 months. RESULTS: The median DWI-ASPECTS was 7 (interquartile range, 6-8). The rates of good outcome, symptomatic hemorrhage, and mortality were not different between high DWI-ASPECTS (scores of 7-10) and intermediate DWI-ASPECTS (scores of 4-6) groups. In patients with an intermediate DWI-ASPECTS, good outcome was achieved in 46.5% (20/43) of patients with successful revascularization, whereas no patients without successful revascularization had a good outcome (P = .016). In multivariate logistic regression analysis, independent predictors of good outcome were age and successful revascularization. CONCLUSIONS: Our study suggested that there were no differences in outcomes between patients with a high DWI-ASPECTS and those with an intermediate DWI-ASPECTS who underwent stent-retriever embolectomy for acute anterior circulation stroke. Thus, patients with an intermediate DWI-ASPECTS otherwise eligible for endovascular therapy may not be excluded from stent-retriever embolectomy or stroke trials.

Endovascular procedures versus intravenous thrombolysis in stroke with tandem occlusion of the anterior circulation.

PURPOSE: Stroke with tandem occlusion within the anterior circulation presents a lower probability of recanalization and good clinical outcome after intravenous (IV) thrombolysis than stroke with single occlusion. The present study describes the impact of endovascular procedures (EPs) compared with IV thrombolysis alone on recanalization and clinical outcome. MATERIALS AND METHODS: Thirty patients with symptom onset less than 4.5 hours and tandem occlusion within the anterior circulation were analyzed retrospectively. Recanalization was assessed per Thrombolysis In Cerebral Infarction (TICI) classification on computed tomography, magnetic resonance imaging, or digital subtraction angiography within 24 hours. Infarct size was detected on follow-up imaging as a dichotomized variable, ie, more than one third of the territory of the middle cerebral artery. Clinical outcomes were major neurologic improvement, independent outcome (90-d modified Rankin Scale [mRS] score), symptomatic intracerebral hemorrhage (sICH; per European Cooperative Acute Stroke Study criteria), and death within 7 days. RESULTS: Patients treated with EPs (n = 14) were significantly younger and had a history of arterial hypertension more frequently than patients treated with IV thrombolysis alone (n = 16). Recanalization (ie, TICI score 2b/3; EP, 64%; IV, 19%; P = .01), major neurologic improvement (EP, 64%; IV, 19%; P = .01), and independent outcome (mRS score ≤ 2; EP, 54% IV, 13%; P = .02) occurred more often in the EP group, whereas infarct sizes greater than one third of the MCA territory (EP, 43%; IV, 81%; P = .03) were observed less often. Rates of sICH (P = .12) and death within 7 days (P = .74) did not differ significantly. CONCLUSIONS: Higher recanalization rate, smaller infarct volume, and better clinical outcome in the EP group should encourage researchers to include this subgroup of patients in prospective randomized trials comparing IV thrombolysis versus EP in stroke.

Outcomes in severe middle cerebral artery ischemic stroke.

BACKGROUND: Severe middle cerebral artery stroke (MCA) is associated with a high rate of morbidity and mortality. We assessed the hypothesis that patient-specific variables may be associated with outcomes. We also sought to describe under-recognized patient-centered outcomes. METHODS: A consecutive, multi-institution, retrospective cohort of adult patients (≤70 years) was established from 2009 to 2011. We included patients with NIHSS score ≥15 and infarct volume ≥60 mL measured within 48 h of symptom onset. Malignant edema was defined as the development of midline brain shift of ≥5 mm in the first 5 days. Exclusion criterion was enrollment in any experimental trial. A univariate and multivariate logistic regression analysis was performed to model and predict the factors related to outcomes. RESULTS: 46 patients (29 female, 17 male; mean age 57.3 ± 1.5 years) met study criteria. The mortality rate was 28% (n = 13). In a multivariate analysis, only concurrent anterior cerebral artery (ACA) involvement was associated with mortality (OR 9.78, 95% CI 1.15, 82.8, p = 0.04). In the malignant edema subgroup (n = 23, 58%), 4 died (17%), 7 underwent decompressive craniectomy (30%), 7 underwent tracheostomy (30%), and 15 underwent gastrostomy (65%). CONCLUSIONS: Adverse outcomes after severe stroke are common. Concurrent ACA involvement predicts mortality in severe MCA stroke. It is useful to understand the incidence of life-sustaining procedures, such as tracheostomy and gastrostomy, as well as factors that contribute to their necessity.

One-year case fatality and disability after posterior circulation infarction in a Chinese hospital-based stroke study.

BACKGROUND AND PURPOSE: Controversy exists as to whether posterior circulation infarction (PCI) has a poorer outcome compared to anterior circulation infarction (ACI). We aimed to investigate whether PCI had different clinical outcomes from ACI in Chinese patients with ischemic stroke. METHODS: Data on ischemic stroke patients with ACI or PCI were collected including demographics, risk factors and 1-month, 3-month, and 1-year case fatality and disability (defined as modified Rankin Scale 3-5). Multivariate regression models were used to analyze predictors for death and disability. RESULTS: Of the 1,962 enrolled cases, 433 (22.1%) had PCI. The case fatality of PCI at 1-month, 3-month and 1-year follow-up (FU) were lower than that of ACI (3.93, 5.3 and 9.7% vs. 7.26, 9.3 and 13.7%, p <0.05), and the proportion of disability was also lower in PCI at 3-month FU (19.6 vs. 29.1%, p<0.001) and 1-year FU (6.5 vs. 15.2%, p<0.001). The adjusted hazard ratio of death for PCI was 0.52 at 1 month (95% CI 0.29-0.94) and 0.52 at 3 months (95% CI 0.31-0.85), and the adjusted odds of disability in patients with PCI was 0.53 at 1 year (95% CI 0.35-0.81). CONCLUSIONS: In our cohort, patients with PCI have a lower risk of death at 1- and 3-month FU and a lower proportion of disability at 1-year FU, which needs to be verified by future studies.

Five-year survival after first-ever ischaemic stroke is worse in total anterior circulation infarcts: the SINPAC cohort.

BACKGROUND: Few studies have addressed predictors of long-term mortality after first-ever ischaemic stroke. METHODS: We prospectively collected data on 361 consecutive patients admitted to 18 neurology departments in Italy for a first-ever ischaemic stroke in 1999, categorized according to the Oxfordshire Community Stroke Project (OCSP) classification. Age, gender, risk factors, previous vascular disease, in-hospital complications, stroke severity, functional status, therapy and living place at admission, discharge and after 6 months were recorded. Follow-up was available for 97% patients at 5 years. RESULTS: Survival probability was 91% (95% CI = 88-94) at 1 month, 84% (80-88) at 6 months and 64% (58-69) at 5 years. Mortality was higher for the TACI (total anterior circulation infarct) group compared to the other categories (p < 0.0001). Hazard ratios for 5-year mortality in the final model were: 5.4 for age >or=65 years (p < 0.0001), 2.8 for TACI (p < 0.0001), 2.7 for previous vascular disease (p < 0.01) and 1.9 for cardio-embolic risk according to the TOAST risk stratification (p < 0.05). CONCLUSIONS: Our study extends the prognostic value of the OCSP classification to 5-year survival.

Intra-arterial thrombolysis using rt-PA in patients with acute stroke due to vessel occlusion of anterior and/or posterior cerebral circulation.

INTRODUCTION: The aim of our study was to evaluate the safety and efficacy of intra-arterial (IA) thrombolysis using recombinant tissue plasminogen activator (rt-PA) in patients with acute stroke due to occlusion in the anterior or posterior circulation. METHODS: We retrospectively analyzed the clinical and radiological data of 88 consecutive patients with acute ischemic stroke who underwent emergency cerebral angiography for the purpose of subsequent IA thrombolysis. The neurological deficit on admission and discharge was graded using the National Institutes of Health Stroke Scale (NIHSS) score. Baseline computer tomography (CT) scans were examined for any signs indicative of cerebral ischemia. The angiographic findings were classified according to the Thrombolysis in Myocardial Infarction (TIMI) score for myocardial infarction. Follow-up CT scans were examined for hemorrhagic complication. RESULTS: Of the 88 patients who underwent IA thrombolysis, 63 presented with complete or partial arterial occlusion in the suspected perfusion area. In these 63 patients, the median NIHSS score dropped from 15 points on admission to 10 points at discharge. The recanalization rate was 52.6% for partial and complete reperfusion. In-hospital mortality was 20.6% (9.1% for carotid, 44.4% for basilar territory occlusion). Intracerebral bleeding (ICB) occurred in 38.6% of the patients with occlusion in the anterior circulation, resulting in these patients presenting a worse clinical outcome than those without ICB. Only minor extracranial bleedings occurred in 20.6% of patients. Patients with ICB had a significantly higher frequency of ischemic signs on the baseline CT scan. CONCLUSION: Occlusion of a cerebral artery is present in about 75% of the patients eligible for thrombolytic therapy. Intra-arterial thrombolysis using rt-PA in patients with acute ischemic stroke can achieve re-vascularization, although ICB remains the major risk factor affecting its efficacy.

[Ischemic insult in the anterior and posterior cerebral circulation]. / Ishemicki inzulti prednje i straznje cerebralne cirkulacije.

In the everyday practice among clinical and etiological classifications for ischemic stroke, the terms strokes in the anterior and posterior cerebral circulation are also in use. The aim of this study was to analyze the frequency of ischemic strokes in the anterior and posterior circulation, their age and sex distribution, risk factors and hospital mortality. In the study it was analyzed 1772 patients with acute ischemic stroke hospitalized at the Department of Neurology Tuzla, Bosnia and Herzegovina, between January 1st 1996 and December 31st 2000. The mean age was 65.5 years (+9.9), 942 (55%) were females. Ischemic strokes for all patients were confirmed with computed tomography, while other data were collected from the standard patients' history charts. Anterior circulation stroke (ACS) had 1408 patients (81.8%), the rest of 314 (18.2%) had posterior circulation stroke (PCS). In the both types females were slightly overrepresented: 784 (56%) in ACS, and 158 (50.5%) in PCS. Moreover, females were significantly older than males: 67 (+9.8) versus 64 (+10) years in ACS (p < 0.001), 67.5 (+10.3) versus 63.5 (+9.2) in PCS (p < 0.001). Hypertension was the major risk factor occurring in 67% patients with ACS and 71 with PCS; heart diseases 54% in the both types, and diabetes in 23% patients with ACS and 20% with PCS. The cortical ischemic lesion was verified in 46% patients with ACS, 41% with PCS; subcortical in 12.5% and 14.5%; and lacunar in 41.5% and 44.5%, respectively. Hospital mortality was 30% (430 patients) for ACS, and 32% (101 patients) for PCS. Hospital mortality was considerably higher among females: 33% versus 28% for ACS (p = 0.03), 38% versus 27% for PCS (p = 0.03). On the basis of our study we can conclude that ischemic strokes in the anterior cerebral circulation are 4/5 of all ischemic strokes at the Department of Neurology Tuzla. Both, anterior and posterior circulation strokes are more frequent in females, witches were in average older than males. The cortical lesion dominated in ACS, and lacunar in PCS. The distribution of risk factors (hypertension, heart diseases, and diabetes) is similar for ACS and PCS, and hospital mortality also; however, mortality rate is higher in females.