NEURORADIOLOGY / ORIGINAL PAPER
The prognostic significance of large vessel occlusion in stroke patients treated by intravenous thrombolysis
1
Department of Neurology, University Hospital, Krakow, Poland
2
Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
3
Department of Dental Prophylaxis and Experimental Dentistry, Jagiellonian University Medical College, Krakow, Poland
Submission date: 2020-11-26
Acceptance date: 2021-01-26
Publication date: 2021-06-09
Pol J Radiol, 2021; 86: 344-352
KEYWORDS
acute stroke (1)thrombolysis (2)mechanical thrombectomy (3)outcome (4)acute strokethrombolysismechanical thrombectomyoutcome
TOPICS
ABSTRACT
Introduction:
According to guidelines, to shorten the treatment window, acute ischaemic stroke (AIS) treatment by intravenous thrombolysis (IVT) can be done based on the results of head computed tomography (CT) without contrast. The impact of large vessel occlusion (LVO) on computed tomography angiography (CTA) in stroke prognosis in patients treated IVT or IVT and mechanical thrombectomy (MT), where indicated, has not yet been studied systematically. We investigated the influence of LVO in consecutive AIS patients on haemorrhagic transformation (HT) on CT 24 h after treatment, mRS < 2 on discharge (unfavourable outcome), and in-hospital mortality.
Material and methods:
We analysed several parameters within 24 h after AIS: demographics, risk factors, mRS score pre-stroke, NIHSS upon admission and 24 h later, several clinical and biochemical parameters, and chronic treatment.
Results:
We registered 1209 patients, of whom 362 (29.9%) received IVT and 108 had MT, where indicated. Admission CTA showed LVO in 197 patients (54.4%). Multivariate regression analysis showed that the presence of LVO and lower delta NIHSS (NIHSS on admission minus NIHSS 24 hours later) were independent parameters affecting HT risk. Multivariate analysis showed that the presence LVO and also older age, female sex, lower delta NIHSS, HT, stroke-associated infection, CRP levels ≥ 10 mg/L, and higher WBC count affected unfavourable outcome on discharge. LVO did not affect in-hospital mortality.
Conclusions:
LVO in AIS patients treated by IVT or IVT and MT affects the risk of HT and unfavourable short-term outcome but not in-hospital mortality.
According to guidelines, to shorten the treatment window, acute ischaemic stroke (AIS) treatment by intravenous thrombolysis (IVT) can be done based on the results of head computed tomography (CT) without contrast. The impact of large vessel occlusion (LVO) on computed tomography angiography (CTA) in stroke prognosis in patients treated IVT or IVT and mechanical thrombectomy (MT), where indicated, has not yet been studied systematically. We investigated the influence of LVO in consecutive AIS patients on haemorrhagic transformation (HT) on CT 24 h after treatment, mRS < 2 on discharge (unfavourable outcome), and in-hospital mortality.
Material and methods:
We analysed several parameters within 24 h after AIS: demographics, risk factors, mRS score pre-stroke, NIHSS upon admission and 24 h later, several clinical and biochemical parameters, and chronic treatment.
Results:
We registered 1209 patients, of whom 362 (29.9%) received IVT and 108 had MT, where indicated. Admission CTA showed LVO in 197 patients (54.4%). Multivariate regression analysis showed that the presence of LVO and lower delta NIHSS (NIHSS on admission minus NIHSS 24 hours later) were independent parameters affecting HT risk. Multivariate analysis showed that the presence LVO and also older age, female sex, lower delta NIHSS, HT, stroke-associated infection, CRP levels ≥ 10 mg/L, and higher WBC count affected unfavourable outcome on discharge. LVO did not affect in-hospital mortality.
Conclusions:
LVO in AIS patients treated by IVT or IVT and MT affects the risk of HT and unfavourable short-term outcome but not in-hospital mortality.
REFERENCES (39)
1.
Powers WJ, Rabinstein AA, Ackerson T, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2018; 49: e46-e99.
2.
Correction to: Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2019; 50: e440-e441.
3.
Less K, Bluhmki E, Kummer R, et al. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Meta-analysis. Lancet 2010; 375: 1695-1703.
4.
Puetz V, Dzialdowski I, Hill MD, et al. Malignant profile detected by CT sangiographic information predicts poor prognosis despite thrombolysis within three hours from symptom onset. Cerebrovasc Dis 2010; 29: 584-591.
5.
Rai A, Cline B, Williams E, et al. Intravenous thrombolysis outcomes in patients presenting with large vessel acute ischemic strokes – CT angiography based prognosis. J Neuroimaging 2015; 25: 239-242.
6.
Zhu W, Xiao L, Lin M, et al. Large-vessel occlusion is associated with poor outcome in stroke patients aged 80 years or older who underwent intravenous thrombolysis. J Stroke Cerebrovasc Dis 2016; 25: 2712-2716.
7.
Smith WS, Lev MH, English JD, et al. Significance of large vessel intracranial occlusion causing acute ischemic stroke and TIA. Stroke 2009; 40: 3834-3840.
8.
Berkhemer OA, Fransen PS, Beumer D, et al. A randomized trial of intraarterial treatment for acute ischemic stroke. N Engl J Med 2015; 372: 11-20.
9.
Jovin T G, Chamorro A, Cobo E, et al. Thrombectomy within 8 hours after symptom onset in ischemic stroke. N Engl J Med 2015; 372: 2296-2306.
10.
Campbell BCV, Mitchell PJ, Kleinig TJ, et al. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372: 1009-1018.
11.
Saver JL, Goyal M, Bonafe A, et al. Stent- retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372: 2285-2295.
12.
Goyal M, Demchuk AM, Menon BK, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372: 1019-1030.
13.
Sacco RL, Kasner SE, Broderick JP, et al. American Heart Association Stroke Council, Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Radiology and Intervention; Council on Cardiovascular and Stroke Nursing; Council on Epidemiology and Prevention; Council on Peripheral Vascular Disease; Council on Nutrition, Physical Activity and Metabolism. An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44: 2064-2089.
14.
Derbisz J, Brzegowy P, Pulyk R, et al. Long-term outcome of acute ischemic stroke with unruptured intracranial aneurysm treated with intravenous thrombolysis. J Vasc Med Surg 2020; 8: 399.
15.
Van Swieten J, Koudstaal P, Visser M, et al. Interobserver agreement for the assessment of handicap in stroke patients. Stroke 1988; 19: 604-607.
16.
Brott T, Adams HP, Olinger CP, et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989; 20: 864-870.
17.
Adams HP Jr, Bendixen BH, Kappelle LJ, et al. Classification of subtype of acute ischemic stroke: Definition for use in a multicenter clinical trial. Stroke 1993; 24: 35-41.
18.
Nowak K, Derbisz J, Peksa J, et al. Post-stroke infection in acute ischemic stroke patients treated by mechanical thrombectomy does not affect long-term outcome. Adv Intern Cardiol 2020; 16: 452-459.
19.
Hacke W, Kaste M, Fieschi C, et al. Randomized double-blind placebo-controlled trial of thrombolytic therapy with intravenous alteplase in acute ischemic stroke (ECAS II). Second European-Australasian Acute Stroke Study Investigators. Lancet 1998; 352: 1245-1251.
20.
Al-Khaled M, Matthis C, Eggers J. Predictors of in-hospital mortality and the risk of symptomatic intracerebral hemorrhage after thrombolytic therapy with recombinant tissue plasminogen activator in acute ischemic stroke. J Stroke Cerebrovasc Dis 2014; 23: 7-11.
21.
Kim DH, Lee DS, Nah HW, et al. Clinical and radiological factors associated with unfavorable outcome after intravenous thrombolysis in patients with mild ischemic stroke. BMC Neurol 2018; 18: 30.
22.
Al-Hussain F, Hussain MS, Molina C, et al. Does the sex of acute stroke patients influence the effectiveness of rt-Pa? BMC Neurol 2014; 14: 60.
23.
Meseguer E, Mazighi M, Labreuche J, et al. Outcomes of intravenous recombinant tissue plasminogen activator therapy according to gender. Stroke 2009; 40: 2104-2110.
24.
Jovanović DR, Beslać-Bumbasirević LJ, Budimkić M, et al. Do women benefit more from systemic thrombolysis in acute ischemic stroke? A Serbian experience with thrombolysis in ischemic stroke (SETIS) study. Clin Neurol Neurosurg 2009; 111: 729-732.
25.
Maestrini I, Strbian D, Gautier S, et al. Higher neutrophil counts before thrombolysis for cerebral ischemia predict worse outcomes. Neurology 2015; 85: 1408-1416.
26.
Liu M, Pan Y, Zhou L, et al. Predictors of post- thrombolysis symptomatic intracranial hemorrhage in Chinese patients with acute ischemic stroke. PLoS One 2017; 12: e0184646.
27.
Liu SY, Cao WF, Wu LF, et al. Effect of glycated hemoglobin index and mean arterial pressure on acute ischemic stroke prognosis after intravenous thrombolysis with recombinant tissuse plasminogen activator. Medicine 2018; 97: e13216.
28.
Nardi K, Engelter S, Strbian D, et al. Lipid profiles and outcome in patients treated by intravenous thrombolysis for cerebral ischemia. Neurology 2012; 79: 1101-1108.
29.
Tang H, Zhang S, Yan S, et al. Unfavorable neurological outcome in diabetic patients with acute ischemic stroke is associated with incomplete recanalization after intravenous thrombolysis. J Neurointerv Surg 2016; 8: 342-346.
30.
Sung SF, Chen YW, Tseng MC, et al. Atrial fibrillation predicts good functional outcome following intravenous tissue plasminogen activator in patients with severe stroke. Clin Neurol Neurosurg 2013; 115: 892-895.
31.
Seet R, Zhang Yi, Wijdicks E F, et al. Relationship between chronic atrial fibrillation and worse outcomes in stroke patients after intravenous thrombolysis. Arch Neurol 2011; 68: 1454-1458.
32.
Padjen V, Bodenant M, Jovanovic DR, et al. Outcome of patients with atrial fibrillation after intravenous thrombolysis for cerebral ischaemia. J Neurol 2013; 260: 3049-3054.
33.
Awadh M, MacDougall N, Santosh C, et al. Early recurrent ischemic stroke complicating intravenous thrombolysis for stroke: incidence and association with atrial fibrillation. Stroke 2010; 41: 1990-1995.
34.
Kimura K, Iguchi Y, Yamashita S, et al. Atrial fibrillation as an independent predictor for no early recanalization after IV-t-PA in acute ischemic stroke. J Neurol Sci 2008; 267: 57-61.
35.
Tseng YJ, Hu RF, Lee ST, et al. Risk factors associated with outcomes of recombinnt tissue plasminogen activator therapy in patients with acute ischemic stroke. Int J Environ Res Public Health 2020; 17: 618.
36.
Foell RB, Silver B, Merino JG, et al. Effects of thrombolysis for acute stroke in patients with pre-existing disability. CMAJ 2003; 169: 193-197.
37.
Förster A, Gass A, Kern R, et al. Gender differences in acute ischemic stroke: etiology, stroke patterns and response to thrombolysis. Stroke 2009; 40: 2428-2432.
38.
Tian MJ, Tayal AH, Schlenk EA. Predictors of poor hospital discharge outcome in acute stroke due to atrial fibrillation. J Neurosci Nurs 2015; 47: 20-26.
39.
Wiszniewska M, Fryze W, Wiśniewska A, et al. Sex-related differences among ischaemic stroke patients treated with intravenous thrombolysis in Poland. Neurol Neurochir Pol 2020; 54: 272-276.
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