Safety of Mechanical Thrombectomy with Combined Intravenous Thrombolysis in Stroke Treatment 4.5 to 9 Hours from Symptom Onset.

BACKGROUND: An extended time window for intravenous thrombolysis (IVT) for acute stroke patients up to 9 hours from symptom onset has been established in recent trials, excluding patients who received mechanical thrombectomy (MT). We therefore investigated whether combined therapy with IVT and MT (IVT+MT) is safe in patients with ischemic stroke and large vessel occlusion (LVO) in an extended time window. METHODS: We retrospectively analyzed patients with anterior circulation ischemic stroke and LVO who were treated within 4.5 to 9 hours after symptom onset using MT with or without IVT. Primary endpoint was the occurrence of any intracranial hemorrhage (ICH). Multivariable logistic regression was used to adjust for potential confounders. RESULTS: In total, 168 patients were included in the study, 44 (26%) were treated with IVT+ MT. 133 (79%) patients had a M1-/distal carotid artery occlusion. Median ASPECT-Score was 8 (IQR 7-10) and complete reperfusion (mTICI 2b-3) was achieved in 132 (79%) patients. 18 (41%) of the patients in the IVT+MT group developed any ICH vs. 45 (36%) patients in the direct MT group (p=0.587). Symptomatic ICH occurred in 5 (11%) patients with IVT+MT vs. 8 (6%) patients receiving direct MT (p=0.295). In multivariable analysis, IVT+MT was not an independent predictor of ICH (adjusted for NIHSS, degree of reperfusion, symptom-onset-to-treatment time and therapy with tirofiban; OR 0.95 [95% CI 0.43-2.08], p=0.896). CONCLUSION: Mechanical thrombectomy in stroke patients seems to be safe with combined intravenous thrombolysis within 4.5 to 9 hours after onset as it did not significantly increase the risk for intracranial hemorrhage.

High-normal PaCO2 values might be associated with worse outcome in patients with subarachnoid hemorrhage - a retrospective cohort study.

BACKGROUND: While both hypercapnia and hypocapnia are harmful in patients with subarachnoid hemorrhage (SAH), it is unknown whether high-normal PaCO2 values are better than low-normal values. We hypothesized that high-normal PaCO2 values have more detrimental than beneficial effects on outcome. METHODS: Consecutive patients with aneurysmal subarachnoid hemorrhage (aSAH) requiring mechanical ventilation treated in a tertiary care university hospital were retrospectively analyzed regarding the influence of PaCO2 on favorable outcome, defined as modified Rankin scale score < 3 at discharge. Primary endpoint was the difference in the proportion of PaCO2 values above 40 mmHg in relation to all measured PaCO2 values between patients with favorable and unfavorable outcome. RESULTS: 150 patients were included. Median age was 57 years (p25:50, p75:64), median Hunt-Hess score was 4 (p25:3, p75:5). PaCO2 values were mainly within normal range (median 39.0, p25:37.5, p75:41.4). Patients with favorable outcome had a lower proportion of high-normal PaCO2 values above 40 mmHg compared to patients with unfavorable outcome (0.21 (p25:0.13, p75:0.50) vs. 0.4 (p25:0.29, p75:0.59)) resulting in a lower chance for favorable outcome (OR 0.04, 95% CI 0.00-0.55, p = 0.017). In multivariable analysis adjusted for Hunt-Hess score, pneumonia and length of stay, elevated PaCO2 remained an independent predictor of outcome (OR 0.05, 95% CI 0.00-0.81, p = 0.035). CONCLUSIONS: A higher proportion of PaCO2 values above 40 mmHg was an independent predictor of outcome in patients with aSAH in our study. The results need to be confirmed in a prospective trial.