Jeffrey Wagner

Epidemiology, Endovascular Treatment, and Prognosis of Cerebral Venous Thrombosis: US Center Study of 152 Patients

Background Cerebral venous thrombosis is a rare cause of stroke that poses diagnostic, therapeutic, and prognostic challenges. Mainstay treatment is systemic anticoagulation, but endovascular treatment is increasingly advocated. Our objectives were to describe the epidemiology, treatment, and prognosis of 152 patients with cerebral venous thrombosis. Methods and Results This was a retrospective study of consecutive cerebral venous thrombosis cases from 2006 to 2013 at a comprehensive stroke center through hospital discharge. Predictors of full recovery (modified Rankin Scale scores 0–1) were analyzed with multiple logistic regression and presented as adjusted odds ratios (AORs) with 95% confidence intervals (CIs). The population was young (average age: 42 years), majority female (69%), and commonly presenting with cerebral edema (63%), and 72% were transferred in. All patients received systemic anticoagulation; 49% (n=73) required endovascular treatment. Reasons for requiring endovascular treatment included cerebral edema, herniation, or hemorrhagic infarct (n=38); neurologic decline (n=17); rethrombosis, persistent occlusion, or clot propagation (n=10); extensive clot burden (n=7); and persistent headache despite anticoagulation (n=1). There were 7 (10%) procedural complications. Recanalization was successful (61%), partial (30%), and unsuccessful (9%). Overall, 60% fully recovered. Positive predictors of full recovery included hormonal etiology, particularly for patients who were transferred in (AOR: 7.06 [95% CI, 2.27–21.96], interaction P=0.03) and who had migraine history (AOR: 4.87 [95% CI, 1.01–23.50], P=0.05), whereas negative predictors of full recovery were cerebral edema (AOR: 0.11 [95% CI, 0.04–0.34], P<0.001) and motor weakness (AOR: 0.28 [95% CI, 0.09–0.96], P=0.04). Conclusions As one of the largest cohort studies, our findings suggest that cerebral edema, history of migraine, and hormonal etiology were prognostic and that endovascular treatment might be a safe and effective treatment for cerebral venous thrombosis when conventional management is inadequate.

Comprehensive analysis of intra-arterial treatment for acute ischemic stroke due to cervical artery dissection

Objective The safety and efficacy of intra-arterial treatment (IAT) in patients with acute ischemic stroke (AIS) due to cervical artery dissection (CeAD) has not been formally studied. The purpose of this study was twofold: first, describe a large series with CeAD treated with IAT; second, analyze outcomes with CeAD receiving IAT versus (a) CeAD not treated with IAT, (b) CeAD receiving intravenous thrombolysis (IVT) alone, and (c) non-CeAD mechanism of AIS receiving IAT. Design Demographics, clinical characteristics, treatment, and outcomes were summarized for all CeAD patients treated with IAT from January 2010 to May 2015. Outcomes included favorable 90 day modified Rankin Scale (mRS) score of 0–2, symptomatic intracerebral hemorrhage (sICH), recanalization (Thrombolysis in Cerebral Infarction 2b-3), procedural complications, and mortality. Outcomes were analyzed with χ2 tests and multivariate logistic regression. Results There were 161 patients with CeAD: 24 were treated with IAT and comprised our target population. Dissections were more common in the internal carotid (n=18) than in the vertebral arteries (n=6). All but one patient had intracranial embolus. IAT techniques included thrombectomy (n=19), IA thrombolysis (n=17), stent (n=14), and angioplasty (n=7). Outcomes included favorable 90 day mRS score of 0–2 in 63%, 4 deaths, 1 sICH, and 3 procedural complications. After adjustment, favorable mRS in our target population was similar to comparison populations: (a) in CeAD, IAT versus no IAT (OR 0.62, p=0.56); (b) In CeAD, IAT versus IVT alone (OR 1.32, p=0.79); and (c) IAT in CeAD versus non-CeAD mechanism of AIS (OR 0.58, p=0.34). Conclusions IAT is a valid alternative therapeutic option for AIS caused by CeAD due to the low complication rate and excellent outcomes observed in this study.

A 24 h Delay in the Redox Response Distinguishes the most Severe StrokePatients from Less Severe Stroke Patients

Objective: Admission measures of stroke severity are often used to assess 30-90 day outcomes. Since some patients have a poor outcome by discharge, we sought to identify a biomarker that distinguishes severities as well as acute outcomes. Disruptions in the equilibrium of the redox system were used as an indicator of stroke severity and acute outcome. Methods: Oxidation reduction potential (ORP), a measure of the redox system, was assessed in plasma at admission and 24 h later in patients admitted with stroke symptoms (n=76). Overall differences in ORP between stroke patients and healthy controls were determined. Within stroke patients, changes in ORP as a function of hospital discharge status, modified Rankin scale and NIHSS were assessed using ANOVA and the ability to predict acute outcome in ischemic stroke patients based on ORP was compared to NIHSS using Receiver Operator Characteristics. Results: Stroke patients had higher ORP levels than healthy controls (p 146.6 mV at admission was associated with a 46 fold increased odds of a good acute outcome. Conclusion: ORP measured at admission identified patients which died or were discharged to hospice based on their lower ORP values. The lower ORP and subsequent increase 24 h later in the most severely affected patients may reflect a failure or a delay in engaging the redox system, a response that may, during acute stages, be beneficial.

A Four-Year Experience of Symptomatic Intracranial Hemorrhage Following Intravenous Tissue Plasminogen Activator at a Comprehensive Stroke Center

BACKGROUND To describe the 4-year experience of symptomatic intracranial hemorrhage (sICH) rate at a high-volume comprehensive stroke center. METHODS All admitted adult (≥18 years) patients presenting with an ischemic stroke from 2010 to 2013 were included in this study. The primary outcome was sICH, defined as any hemorrhage with neurological deterioration (change in National Institutes of Health Stroke Scale score ≥4) within 36 hours of intravenous tissue plasminogen activator (IV-tPA) treatment, or any hemorrhage resulting in death. Secondary outcomes were in-hospital mortality and having a favorable modified Rankin Scale (mRS) score (≤2). RESULTS A total of 1925 did not receive intravascular (IV) or intra-arterial (IA) therapy; only 451 received IV therapy; and 175 received both IV and IA therapies. In IV-only patients, the overall rate of sICH was 2.2%; in IV and IA patients, the rate was 5.7%; and in patients who received no therapy, the rate was .4%. The IV-only group had an sICH rate of .9% in 2013. There were no differences in the adjusted odds of dying in the hospital between the study groups. IV-only treatment offered significantly better odds of achieving a favorable functional outcome, compared to no therapy, among patients with moderate stroke severity, whereas IV and IA treatments offered significantly better odds among patients with severe strokes. The odds of achieving a favorable functional outcome by discharge were decreased by 97% if patients suffered an sICH (OR = .03, 95%CI = .004, .19). CONCLUSIONS Despite an increased risk of sICH with IV-tPA, treatment with IV-tPA continues to be associated with increased odds of a favorable discharge mRS.

How a CT-Direct Protocol at an American Comprehensive Stroke Center Led to Door-to-Needle Times Less Than 30 Minutes

Background and Purpose: The safety and efficacy of intravenous tissue plasminogen activator (IV tPA) following acute ischemic stroke (AIS) is dependent on its timely administration. In 2014, our Comprehensive Stroke Center designed and implemented a computed tomography-Direct protocol to streamline the evaluation process of suspected patients with AIS, with the aim of reducing door-to-needle (DTN) times. The objectives of our study were to describe the protocol development and implementation process, and to compare DTN times and symptomatic intracranial hemorrhage (sICH) rates before and after protocol implementation. Methods: Data were prospectively collected for patients with AIS receiving IV tPA between January 1, 2010, and May 31, 2015. The DTN times, examined as median times and time treatment windows, and sICH rates were compared pre- and postimplementation. Results: Two hundred ninety-five patients were included in the study. After protocol implementation, median DTN times were significantly reduced (38 vs 28 minutes; P < .001). The distribution of patients treated in the three time treatment windows described below changed significantly, with an increase in patients with DTN times of 30 minutes or less, and a decrease in patients with DTN times 31 to 60 minutes and over 60 minutes (P < .001). There were two cases of sICH prior to implementation and one sICH case postimplementation. Conclusions: The implementation of a protocol that streamlined the processing of suspected patients with AIS significantly reduced DTN time without negatively impacting patient safety.

Age ≥80 Years Is Not a Contraindication for Intra-Arterial Therapy after Ischemic Stroke.

Background: Clinical trials confirmed the safety and efficacy of intra-arterial therapy (IAT) in the management of ischemic stroke. At a community hospital, we compared outcomes in patients aged ≥80 and patients in the age range 55-79 years receiving IAT following ischemic stroke. Methods: Data were retrospectively abstracted for ischemic stroke patients ≥55 years treated with IAT at an urban comprehensive stroke center between 2010 and 2013. Baseline demographics, incidence of symptomatic intracranial hemorrhage (sICH), in-hospital mortality, discharge modified Rankin scale (mRS) score (favorable ≤2) and improvement in National Institutes of Health Stroke Scale Score (NIHSS; decreased score at discharge) were compared between patients in the age range 55-79 and patients ≥80 years. Data were analyzed using univariate analyses and multivariate logistic regression. Results: IAT was performed in 239 patients with ischemic stroke; 63 (26.4%) were ≥80 years. When compared to patients aged 55-79, the elderly patients were more often female and non-smokers, with a history of atrial fibrillation. No differences were observed in those ≥80 years compared to patients in the age range 55-79 years for sICH (10 vs. 5%, p = 0.23), mortality (24 vs. 18%, p = 0.28), favorable discharge mRS score (13 vs. 19%, p = 0.27), or improvement in NIHSS (83 vs. 92%, p = 0.10). The nonsignificant association of age with the outcomes persisted after adjusting for covariates and when analyzing the subset of patients who received IAT only. Conclusions: These findings suggest that in a cohort not subject to the criteria of a clinical trial, age ≥80 years should not be a contraindication to IAT.