Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

Magoufis, Georgios; Safouris, Apostolos; Guy, Rebecca; Kargiotis, Odysseas; Psychogios, Klearchos; Krogias, Christos; Palaiodimou, Lina; Spiliοpoulos, Stavros; Polizogopoulou, Eftihia; Mantatzis, Michael; Finitsis, Stephanos; Karapanayiotides, Theodoros; Ellul, John; Bakola, Eleni; Brountzos, Elias; Mitsias, Panayiotis; Giannopoulos, Sotirios; Tsivgoulis, Georgios

doi:10.1177/17562864211021182

Cited by 12 publications

(6 citation statements)

References 186 publications

(323 reference statements)

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“…Previously, EVT for acute ischemic stroke with LVO was recommended within specific time windows, especially in those within the 6 h from stroke onset. Though the potentially salvageable tissue is affected by the severity and duration of ischemia, the speed of "tissue clock" may differ in individuals [19]. Recent trials have shown the benefits of EVT compared to the best medical treatment during the extended time of 6-24 h in image-based selected patients [1].…”

Section: Discussionmentioning

confidence: 99%

Early Response to Endovascular Thrombectomy after Stroke: Early, Late, and Very Late Time Windows

Ryu

Bae

et al. 2022

Cerebrovasc Dis

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Background and Purpose: Endovascular thrombectomy (EVT) has benefits in selected patients 6–24 h after stroke onset. However, the response to EVT >24 h after stroke onset is still unclear. We compared the early response to EVT in patients with different time windows. Methods: Patients who underwent EVT in an emergency setting were enrolled and categorized according to when EVT was performed: within 6 (early), 6–24 (late), and >24 h (very late) after stroke onset. Early neurological improvement (ENI) and deterioration (END) were defined as improvement and worsening, respectively, of National Institutes of Health Stroke Scale (NIHSS) score by ≥4 points after EVT. The three groups’ clinical characteristics and response to EVT were compared. We also investigated factors associated with ENI and END. Results: During study period, 274 patients underwent EVT (109 early, 104 late, and 61 very late). Patients who underwent EVT very late were younger (p = 0.007), had smaller ischemic cores, and had lower initial NIHSS scores (8 ± 5) than those who underwent EVT early (14 ± 6) and late (13 ± 7; p < 0.001). Stroke mechanisms also differed according to the time window (p < 0.001): cardioembolism was more common after early EVT, whereas large-artery atherosclerosis was more prevalent among patients who underwent EVT very late. ENI was significantly more common after early (60.6%) and late EVT (51.0%) than after very late EVT (29.5%; p = 0.001); however, rates of END did not differ (11.0%, 13.5%, and 4.9%, respectively). ENI was independently associated with male, higher NIHSS score, and early and late EVT. END was associated with failure of recanalization. Conclusions: ENI was more observed and associated with early and late EVT. Highly selected patients receiving very late EVT may not benefit from ENI but may still have a chance to prevent END. The occurrence of END was associated not with time window but with failure of recanalization.

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Section: Discussionmentioning

confidence: 99%

Early Response to Endovascular Thrombectomy after Stroke: Early, Late, and Very Late Time Windows

Ryu

Bae

et al. 2022

Cerebrovasc Dis

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“…Recombinant tissue plasminogen activator was given intravenously within 4.5 h after symptom onset in indicated patients [9]. Patients underwent endovascular treatment in accordance with the national clinical practice guideline and local protocol [10]. The individual stroke risk and the bleeding risk in patients with AF were calculated using the CHA2DS 2-VAS c -score and the HAS-BLED score, respectively.…”

Section: Participants and Clinical Datamentioning

confidence: 99%

“…There were no significant differences in terms of demographics and vascular risk factors between the two groups. Compared with those without RVR, patients with RVR had higher initial NIHSS scores (10 [5-16] vs. 7 [2][3][4][5][6][7][8][9][10][11][12][13][14]; p = 0.001), higher prevalence of persistent AF (95.3 vs. 61.5%; p < 0.001), lower EF (56 ± 11 vs. 59 ± 8%; p = 0.006), and a higher proportion of patients with a poor outcome at 3 months (mRS 3-6; 54.7 vs. 38.0%; p = 0.004). Prior history of taking angiotensin receptor blocker/angiotensin-converting enzyme inhibitor (24.4 vs. 36.5%; p = 0.030) and antiarrhythmic drugs (0 vs. 6.0%; p = 0.020) were lower in those with RVR than without.…”

Section: Comparison Between Patients With and Without Rvrmentioning

confidence: 99%

Association between Rapid Ventricular Response and Stroke Outcomes in Atrial Fibrillation-Related Cardiac Embolic Stroke

Jeong

Park

et al. 2023

Cerebrovasc Dis

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Introduction: Patients with atrial fibrillation-related stroke (AF-stroke) are prone to developing rapid ventricular response (RVR). We investigated whether RVR is associated with initial stroke severity, early neurological deterioration (END) and poor outcome at 3 months. Methods: We reviewed patients who had AF-stroke between January 2017 and March 2022. RVR was defined as having heart rate >100 beats per minute on initial electrocardiogram. Neurological deficit was evaluated with National Institutes of Health Stroke Scale (NIHSS) score at admission. END was defined as increase of ≥2 in total NIHSS score or ≥1 in motor NIHSS score within first 72 h. Functional outcome was score on modified Rankin Scale at 3 months. Mediation analysis was performed to examine potential causal chain in which initial stroke severity may mediate relationship between RVR and functional outcome. Results: We studied 568 AF-stroke patients, among whom 86 (15.1%) had RVR. Patients with RVR had higher initial NIHSS score (p < 0.001) and poor outcome at 3 months (p = 0.004) than those without RVR. The presence of RVR [adjusted odds ratio (aOR) = 2.13; p = 0.013] was associated with initial stroke severity, but not with END and functional outcome. Otherwise, initial stroke severity [aOR = 1.27; p = <0.001] was significantly associated with functional outcome. Initial stroke severity as a mediator explained 58% of relationship between RVR and poor outcome at 3 months. Conclusion: In patients with AF-stroke, RVR was independently associated with initial stroke severity but not with END and functional outcome. Initial stroke severity mediated considerable proportion of association between RVR and functional outcome.

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“…A large proportion of the included patients (138 out of 316) finally received CTP, and among them the vast majority (91%) had a penumbral pattern. 82 The low percentage of patients with absence of target mismatch (9%) could be explained by the fact that poor collaterals, which were an exclusion criterion in the ESCAPE trial, are most likely associated with non-penumbral patterns. This observation implies the significant overlap between CTP perfusion values and the different collateral grades (good, moderate, and poor tissue 'perfusion') as assessed with the qualitative method of ESCAPE trial.…”

Section: Mt In the 0-6 Hours Windowmentioning

confidence: 99%

Advanced Imaging in the Current Era of Acute Reperfusion Therapies

Psychogios¹,

Kargiotis²,

Safouris³

et al. 2023

J Neurosonol Neuroimag

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Reperfusion of the ischemic brain parenchyma with intravenous thrombolysis and/or mechanical thrombectomy is the cornerstone of acute ischemic stroke treatment. A paradigm shift from “time is brain” to a more precision medicine approach now called “imaging is brain”, has taken place during the last decade. This transformation has been fueled by the progress in neuroimaging. Advanced Neuroimaging incorporates perfusion imaging in order to depict real-time cerebral perfusion disturbances and provide maps of the penumbra and ischemic core that will inform individualized clinical decisions. Advance neuroimaging has now a fundamental role in triaging patients that will receive reperfusion treatments beyond the conventional time windows of 4.5 hours for intravenous thrombolysis and 6 hours for mechanical thrombectomy. We provide a narrative review of all the pivotal observational studies and randomized-controlled clinical trials that supported the use of advance neuroimaging, as well as technical issues and pitfalls that may be useful for its implementation in routine clinical practice.

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Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach

Cited by 12 publications

References 186 publications

Early Response to Endovascular Thrombectomy after Stroke: Early, Late, and Very Late Time Windows

Early Response to Endovascular Thrombectomy after Stroke: Early, Late, and Very Late Time Windows

Association between Rapid Ventricular Response and Stroke Outcomes in Atrial Fibrillation-Related Cardiac Embolic Stroke

Advanced Imaging in the Current Era of Acute Reperfusion Therapies

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