Efficacy of peripheral interventional radiologists performing endovascular stroke therapy guided by CT perfusion triage of patients.

PURPOSE: To assess safety and efficacy of intraarterial mechanical thrombectomy for treatment of ischemic stroke in a community hospital by peripheral interventional radiologists employing computed tomography (CT) perfusion imaging for patient selection. MATERIALS AND METHODS: Forty patients, 11 men (27.5%) and 29 women (72.5%), were treated between February 2008 and October 2011. Eligible patients had a National Institutes of Health Stroke Scale (NIHSS) score greater than 8 and diagnosis of large-vessel ischemic stroke by head CT angiogram, and met previously reported CT perfusion imaging triage criteria. RESULTS: The baseline NIHSS score was 18.0 ± 7.9 (range, 8-35). Sixteen patients (40%) had a baseline NIHSS score greater than 20. Symptom onset was unknown in five patients. Symptom onset to device time in the remaining 35 patients was 254.8 minutes ± 150.9 (range, 75-775 min). A total of 65% of patients showed thrombolysis in cerebral infarction (TICI) 2a, 2b, or 3 flow following the procedure. Symptomatic intracranial hemorrhage was seen in four patients (10.0%). At 90 days, 32 patients (80%) were alive and eight (20%) had died. The modified Rankin scale (mRS) score at 90 days was no more than 2 in 20 patients (50.0%). The mean mRS score at 90 days was 2.9 ± 2.0 (range, 0-6). NIHSS score at 90 days was 5.1 ± 6.1 (range, 0-24). In patients with successful recanalization (ie, TICI 2 or 3 flow), a good clinical outcome (ie, mRS score ≤ 2) was achieved in 65.3% of patients (mean, 2.4 ± 1.9; range, 0-6), and 90-day mortality rate was 15.4%, compared with 28.6% in patients with TICI 0/1 flow. CONCLUSIONS: Peripheral interventional radiologists who use CT perfusion imaging for patient triage can have good neurologic outcomes and provide sustainable, safe, and complete around-the-clock coverage for endovascular stroke treatment.

Delayed catastrophic intracerebral hemorrhage preceded by progressive recovery after carotid stenting for acute ischemic stroke.

BACKGROUND: Hemorrhagic transformation (HT) is a feared complication of reperfusion therapy for treatment of acute ischemic stroke. Generally, HT occurs within 24-36 hours after thrombolysis. SUMMARY OF CASE: We present a case of a fatal symptomatic HT of an infarction that occurred 7 days after acute ischemic stroke which was preceded by a remarkable recovery following a combination of acute revascularization therapies. CONCLUSION: Fatal symptomatic HT is a rare potential complication that can occur after several days of treatment of acute ischemic stroke.

Previous statin use is not associated with an increased prevalence or degree of gradient-echo lesions in patients with acute ischemic stroke or transient ischemic attack.

BACKGROUND AND PURPOSE: Microhemorrhages on gradient-echo T2*-weighted MRI sequences are often found in patients with cerebrovascular disease and are related to intracerebral hemorrhage. Because statin therapy is associated with increased risk of intracerebral hemorrhage, we investigated whether statin use was also associated with microhemorrhages in patients with acute ischemic stroke or transient ischemic attack. METHODS: We performed a retrospective analysis on prospectively collected data from a stroke registry containing patients with acute ischemic stroke or transient ischemic attack. The primary and secondary outcome variables were the prevalence and degree of microhemorrhages as detected on gradient-echo MRI sequences and categorized as mild (1-2), moderate (3-10), or severe (>10). The location of the microhemorrhages was noted and rated by 2 neuroradiologists. Previous use of statins and other covariates were assessed as potential predictors. RESULTS: Three hundred forty-nine patients were admitted from June 2008 to July 2009, and 300 of which were analyzed. Microhemorrhages were detected in 70 subjects (23%); 35 had only lobar lesions, 16 had only deep lesions, and 19 had both lobar and deep lesions. On univariate and multivariate analysis, statin therapy was not associated with the prevalence (OR, 0.73; 95% CI, 0.36-1.51; P=0.40) or degree of microhemorrhages modeled for lesser severity (OR, 2.31; 95% CI, 0.61-8.75; P=0.22). CONCLUSIONS: Previous statin therapy was not associated with the prevalence or degree of microhemorrhages in patients with acute ischemic stroke or transient ischemic attack. The association between statins and intracerebral hemorrhage does not appear to be mediated through microhemorrhages.

Endovascular stroke therapy: a single-center retrospective review.

OBJECT: Endovascular treatment of acute ischemic stroke delivers direct therapy at the site of an occluded cerebral artery and can be employed beyond the 3-4.5-hour window limit set for intravenous recombinant tissue plasminogen activator. In this paper, the authors report their experience with various endovascular therapies in acute ischemic stroke. METHODS: The authors conducted a retrospective review of their clinical database for acute ischemic stroke in large-vessel cerebral territories that underwent endovascular treatment between May 2005 and February 2009. Endovascular treatment was defined as pharmacological and/or mechanical intervention, angioplasty, stenting, or a combination of these methods. Admission National Institutes of Health Stroke Scale and the modified Rankin Scale scores were recorded. Thrombolysis in Myocardial Infarction (TIMI) scores of 0, 1, 2A, 2B, and 3 were used to define recanalization. RESULTS: Forty procedures were performed in 39 patients, with 1 patient having sequential bilateral strokes. Nine patients were lost to follow-up after discharge. Strokes in the carotid artery circulation occurred in 82.5% of cases, and those in the vertebral-basilar territory occurred in 17.5%. The Merci device was used in 22 (55%) of 40 procedures, and the Penumbra device in 9 (22.5%) of 40. Angioplasty was performed in 15 (37.5%) of 40 procedures, and intraarterial recombinant tissue plasminogen activator was administered in 23 (57.5%) of 40 procedures. In 23 (57.5%) of 40 cases, multiple recanalization methods were used. The recanalization rate for all methods was 60%. The recanalization rate from TIMI Score 0/1 occlusions was 71.4% (20 of 28). An estimated modified Rankin Scale score of ≤ 2 was obtained in 11 (36.7%) of 30 cases. The overall mortality rate was 26.7% (8 of 30). Intracerebral hemorrhage at 24 hours postprocedure was noted in 17 (42.5%) of 40 cases, 3 (7.5%) of which were symptomatic. CONCLUSIONS: The authors' institution performs endovascular stroke treatment with a safety and efficacy profile comparable to those of other major endovascular stroke therapy studies. Recanalization was associated with an improved clinical outcome. Protocols to maximize efficient triage of patients and better documentation of stroke treatments can assist in further studies.