DRAGON score predicts functional outcomes in acute ischemic stroke patients receiving both intravenous tissue plasminogen activator and endovascular therapy.

BACKGROUND: The DRAGON score, which includes clinical and computed tomographic (CT) scan parameters, predicts functional outcomes in ischemic stroke patients treated with intravenous tissue plasminogen activator (IV tPA). We assessed the utility of the DRAGON score in predicting functional outcome in stroke patients receiving both IV tPA and endovascular therapy. METHODS: A retrospective chart review of patients treated at our institution from February 2009 to October 2015 was conducted. All patients with computed tomography angiography (CTA) proven large vessel occlusions (LVO) who underwent intravenous thrombolysis and endovascular therapy were included. Baseline DRAGON scores and modified Rankin Score (mRS) at the time of hospital discharge was calculated. Good outcome was defined as mRS ≤3. RESULTS: Fifty-eight patients with LVO of the anterior circulation were studied. The mean DRAGON score of patients on admission was 5.3 (range, 3-8). All patients received IV tPA and endovascular therapy. Multivariate analysis demonstrated that DRAGON scores ≥7 was associated with higher mRS (P < 0.006) and higher mortality (P < 0.0001) compared with DRAGON scores ≤6. Patients with DRAGON scores of 7 and 8 on admission had a mortality rate of 3.8% and 40%, respectively. CONCLUSIONS: The DRAGON score can help predict better functional outcomes in ischemic stroke patients receiving both IV tPA and endovascular therapy. This data supports the use of the DRAGON score in selecting patients who could potentially benefit from more invasive therapies such as endovascular treatment. Larger prospective studies are warranted to further validate these results.

Incidence and outcome of procedural distal emboli using the Penumbra thrombectomy for acute stroke.

BACKGROUND: The Penumbra system is effective for recanalization of the primary arterial occlusion (PAO) in acute stroke. However, clinical outcomes are not as promising. The authors hypothesized that the formation of procedural distal emboli (PDE) during mechanical thrombectomy may lead to poorer patient outcomes. DESIGN/METHODS: A retrospective review of patients with acute ischemic stroke treated with the Penumbra system was undertaken. Patients' outcome was evaluated by comparing discharge National Institute of Health stroke scale and modified Rankin score (mRS) of patients with and without PDE. RESULTS: Out of 20 patients reviewed, recanalization of PAO was 100%. Six patients (30%) were confirmed to have PDE, of which two died (33.3%) and one (16.7%) had mRS of 2 or less. Of the 14 patients without PDE, three died (21.4%) and six (42.9%) had mRS of 2 or less. In the patient group who survived, mean National Institute of Health stroke scale decrease was only 2.3 in patients with PDE versus a decrease of 10.6 in patients without PDE. CONCLUSIONS: In spite of PAO recanalization, distal emboli formed subsequent to Penumbra thrombectomy may contribute to poorer clinical outcome in acute stroke patients.

Recombinant human factor VIIa-induced alterations in tissue factor and thrombomodulin in patients with advanced liver cirrhosis.

BACKGROUND: Recombinant human factor VIIa (rhFVIIa) is used to treat hemophilia and occasionally individuals with liver disease. The aim of the present study was to investigate the consequences of rhFVIIa in individuals with advanced liver disease in an attempt to understand the mechanism of action of rhFVIIa in this unique population. METHODS: Levels of plasma tissue factor, plasminogen activator inhibitor-1, tissue factor pathway inhibitor, fibrin split products, D-dimers and free thrombomodulin were measured following the administration of rhFVIIa in 17 subjects. The results were compared to normal controls. RESULTS: The prothrombin time declined from 20.2 +/- 2.8 s to 14.3 +/- 3.9 s (P < 0.01). No change in the activated partial thromboplastin time occurred. A 15.6% reduction in thrombomodulin was observed (P < 0.05). A mean 75.2% reduction in plasma tissue factor occurred (P < 0.01). Tissue factor pathway inhibitor levels declined to less than the control value (P < 0.05). No changes in plasminogen activator inhibitor-1, fibrin split products or D-dimer levels occurred. CONCLUSIONS: These data demonstrate that rhFVIIa administration to individuals with liver disease results in (i) a transient improvement in the prothrombin time; (ii) no change in the activated partial thromboplastin time; and (iii) a marked reduction in the levels of thrombomodulin and tissue factor. These data suggest that rhFVIIa binds tissue factor and enhances tissue factor and thrombomodulin clearance from the circulation.