Background: Hyperdense middle cerebral artery sign (HMCAS) on CT scan before stroke thrombolysis is associated with increased risk for haemorrhage and unfavourable outcome in several small studies. Methods: We examined baseline characteristics, intracranial haemorrhage and outcomes of intravenous thrombolysis in patients with and without HMCAS using the internet-based Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register. Symptomatic intracerebral haemorrhage (SICH) was defined as a National Institute of Health Stroke Scale (NIHSS) score decrease of ≥4 points plus type 2 parenchymal haemorrhage on imaging [Safe Implementation of Thrombolysis in Stroke Monitoring Study (SITS-MOST) definition], or any haemorrhage on follow-up imaging combined with a decrease of at least 1 point on the NIHSS [randomized controlled trial (RCT) definition]. Three-month outcomes were mortality and independence (modified Rankin scale score = 0–2). Results: 1,905 of 10,023 (19.0%) patients had HMCAS. Patients with HMCAS (vs. no HMCAS) were younger (median age 68 vs. 70 years, p < 0.001), had severer stroke (baseline NIHSS score 17 vs. 11, p < 0.05), higher mortality [23% (95% CI 20.0–25.1) vs. 13% (95% CI 12.1–13.7)] and lower independence [31% (95% CI 28.5–33.0) vs. 56% (95% CI 54.8–57.2)]. SICH rates per the SITS-MOST were 1.3% (95% CI 0.8–1.9) versus 1.8% (95% CI 1.5–2.1) and per the RCT definition 10.3% (95% CI 9.0–11.8) versus 6.8% (95% CI 6.2–7.3). In multivariable analysis, HMCAS was not an independent predictor of SICH but of mortality and independence per the SITS-MOST. Conclusions: HMCAS patients had severer stroke and a worse 3-month outcome. The risk for SICH per the SITS-MOST definition was similar compared to non-HMCAS patients, although increased per the RCT definition. There is not sufficient evidence to exclude these patients from intravenous thrombolysis. Combined treatment approaches might be considered in the perspective of the severe outcome and evaluated in RCTs.

for the Safe Implementation of Thrombolysis in Stroke (SITS) InvestigatorsBackground and Purpose-Early neurological improvement (ENI) after thrombolytic therapy of acute stroke has been linked with recanalization and favorable outcome, although its definition shows considerable variation. We tested the ability of ENI, as defined in previous publications, to predict vessel recanalization and 3-month functional outcome after intravenous thrombolysis recorded in an extensive patient cohort in the Safe Implementation of Thrombolysis in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Methods-Of 21 534 patients registered between December 2002 and December 2008, 798 patients (3.7%) had CT-or MR angiography-documented baseline vessel occlusion and also angiography data at 22 to 36 hours post-treatment. ENI definitions assessed at 2 hours and 24 hours post-treatment were (1) National Institutes of Health Stroke Scale (NIHSS) score improvement Ն4 points from baseline; (2) NIHSS 0, 1, or improvement Ն8; (3) NIHSS Յ3 or improvement Ն10; (4) improvement by 20%; (5) 40% from baseline; or (6) NIHSS score 0 to 1. Receiver operating curve analysis and multiple logistic regression were performed to evaluate the association of ENI with vessel recanalization and favorable functional outcome (modified Rankin Scale score 0 to 2 at 3 months). Results-ENI at 2 hours had fair accuracy to diagnose recanalization as derived from receiver operating curve analysis.Definitions of improvement based on percent of NIHSS score change from baseline demonstrate better accuracy to diagnose recanalization at 2 hours and 24 hours than the definitions based on NIHSS cutoffs (the best performance at 2 hours was area under the curve 0.633, sensitivity 58%, specificity 69%, positive predictive value 68%, and negative predictive value 59% for 20% improvement; and area under the curve 0.692, sensitivity 69%, specificity 70%, positive predictive value 70%, and negative predictive value 62% for 40% improvement at 24 hours). ENI-predicted functional outcome with OR 2.8 to 6.0 independently from recanalization in the angiography cohort (nϭ695) and with OR of 6.9 to 9.7 in the whole cohort (nϭ18 181). Key Words: early neurological improvement Ⅲ recanalization Ⅲ stroke Ⅲ thrombolysis Ⅲ vessel occlusion E arly neurological improvement (ENI) after thrombolytic therapy of acute stroke has been shown to be a favorable prognostic sign, 1-5 because ENI is usually associated with recanalization of previously occluded vessels 6 -11 and good functional outcome. 1,12,13 Clinical improvement is considered a consequence of successful recanalization, which is the aim of acute stroke treatment. 12,14 Because it was shown that ENI may follow the recanalization pattern very closely, ENI may be regarded by a clinician as an indicator of effective thrombolytic therapy. 1,8 -10,15 In clinical practice of stroke centers, ENI after intravenous thrombolysis is regarded as a favorable sign and may prevent [23][24][25][26] or from studies with assessment of vessel p...

Background and purpose: Hyperdense middle cerebral artery sign (HMCAS) on CT is a well known indication of thromboembolic arterial occlusion. Its disappearance after thrombolytic therapy is poorly described. Taking the rate of HMCAS disappearance as a surrogate for MCA recanalisation, its prognostic value after intravenous thrombolysis was examined. Methods: 1905 stroke patients with HMCAS on admission CT scan in the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register (SITS-ISTR) were studied. On follow-up CT scans 22-36 h after thrombolysis, HMCAS disappeared in 831 cases, persisted in 788 and was uncertain in 122; followup CT was not done in 164 cases. Results: Patients whose HMCAS disappeared were younger (median age 67 years vs 69 years for persistent; p = 0.03), with milder stroke (admission National Institute of Health Stroke Scale (NIHSS) score was 16 vs 17; p,0.005) and were less likely to have early infarct signs on admission CT (26% vs 33%; p,0.005). Patients with disappearing HMCAS were more likely to have early improvement in NIHSS score (median improvement 2 vs 0 at 2 h; 4 vs 1 at 24 h), be independent at 3 months (42% vs 19%), with fewer deaths (15% vs 30%) than those with persistent HMCAS. In multivariate analysis, HMCAS disappearance independently predicted functional independence and survival. Early NIHSS improvement independently predicted HMCAS disappearance. Conclusions: HMCAS disappeared after intravenous thrombolysis in about half of cases and these patients had twice as good outcomes compared with those with persistent HMCAS. The prognosis in patients with MCA occlusion that persists after intravenous thrombolysis is poor, which may indicate the need for an alternative treatment approach to this subgroup.In acute ischaemic stroke, hyperdense middle cerebral artery sign (HMCAS) on admission CT scan is a known indication of middle cerebral artery occlusion.

Introduction Despite the availability of prevention and therapies of stroke, their implementation in clinical practice, even of low-cost ones, remains poor. In 2015, the European Stroke Organisation (ESO) initiated the ESO Enhancing and Accelerating Stroke Treatment (EAST) program, which aims to improve stroke care quality, primarily in Eastern Europe. Here, we describe its methods and milestones. Patients and methods The ESO EAST program is using an implementation strategy based on a ‘detecting-understanding-reducing disparities’ conceptual framework: stroke care quality is first measured (after developing a platform for data collection), gaps are identified in the current service delivery, and ultimately feedback is provided to participating hospitals, followed by the application of interventions to reduce disparities. The ESO EAST program is carried out by establishing a stroke quality registry, stroke management infrastructure, and creating education and training opportunities for healthcare professionals. Results Program management and leadership infrastructure has been established in 19 countries (Country Representatives in 22 countries, National Steering Committee in 19 countries). A software platform for data collection and analysis: Registry of Stroke Care Quality was developed, and launched in 2016, and has been used to collect data from over 90,000 patients from >750 hospitals and 56 countries between September 2016 and May 2019. Training in thrombolysis, nursing and research skills has been initiated. Discussion ESO EAST is the first pan-Eastern European (and beyond) multifaceted quality improvement intervention putting evidence-informed policies into practice. Continuous monitoring of stroke care quality allows hospital-to-hospital and country-to-country benchmarking and identification of the gaps and needs in health care.

P atients with major cerebral artery occlusion represent the most severe cases of ischemic stroke, 1 for whom prompt recanalization would offer an alternative to a very unfavorable outcome. 2 We have previously demonstrated that hyperdense middle cerebral artery sign, which indicates proximal middle cerebral artery occlusion, disappears after intravenous thrombolysis (IVT) in approximately half of cases, and this disappearance, implying vessel recanalization (although not verified as its marker), is associated with lower mortality and better functional outcome.3 Nevertheless, a large proportion of patients (45% in our previous study) 3 does not achieve vessel recanalization by IVT only. The need for additional recanalizing interventions in this group has been discussed 4-8 because their 3-month survival and independence are unsatisfactory with IVT only. 3,9,10 Several newer combined methods have been suggested for rescue reperfusion in patients with stroke with large vessel occlusion after unsuccessful IVT treatment, such as intra-arterial thrombolysis and mechanical retrieval of the clot.11-15 Combination of IVT and endovascular treatment of major vessel occlusion (intra-arterial thrombolysis and Background and Purpose-Recanalization status after intravenous thrombolysis (IVT) in patients with ischemic stroke is a reference point to proceed with a rescue reperfusion intervention, although early neurological improvement (NI) may preclude endovascular procedures. We aimed to evaluate the importance of restoration of blood flow at the arterial occlusion site in subgroups of patients with stroke stratified by early NI after IVT. Methods-The following patients were recruited from the Safe Implementation of Treatment in Stroke-International Stroke Thrombolysis Register: (1) with baseline vessel occlusion documented by computed tomographic (CT) or magnetic resonance (MR) angiography and follow-up angioimaging between 22 and 36 hours after IVT available; and (2) with dense cerebral artery sign on admission CT scan and results of follow-up CT reported. Recanalization at 24 hours was defined as absence of vessel occlusion or as resolution of dense cerebral artery sign on follow-up 22-to 36-hour imaging. NI was assessed at 2 hours and 24 hours after IVT and was defined as improvement by 20% from baseline National Institute of Health Stroke scale score. Primary outcome measure was independence, defined as modified Rankin scale score 0 to 2 after 3 months. Results-Of 28136 cases registered between December 2003 and November 2009, 5324 cases (19%) met the inclusion criteria. Patients with both NI at 2 hours post-treatment and vessel recanalization had the best chances to achieve independence at 3 months (adjusted odds ratio, 15.8; 95% confidence interval, 12.5-20.0), followed by those who had NI despite persistent occlusion (adjusted odds ratio, 4.7; 95% confidence interval, 3.6-6.1); and those without NI despite recanalization (adjusted odds ratio, 2.7; 95% confidence interval, 2.2-3.3). Conclusions-Recanalization of an occ...