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1.
Stroke ; 49(5): 1286-1289, 2018 05.
Artigo em Inglês | MEDLINE | ID: mdl-29618557

RESUMO

BACKGROUND AND PURPOSE: Despite the recent technical evolution of the endovascular treatment of acute ischemic stroke, late and incomplete recanalization can be achieved after several maneuvers but with a potentially higher risk of futile reperfusion and complications, such as clot fragmentation. The aim of this article is to investigate the impact of the angiographic phenotype of M1-middle cerebral artery occlusions, classified as regular and irregular in aspect, on the results of treatment by stent retrievers (SRs) or contact aspiration (CA). METHODS: From January to April 2016, 84 consecutive patients, admitted for acute ischemic stroke with a middle cerebral artery occlusion, were treated by endovascular therapy. Among them, 60 patients (26M, 34F, median age, 70.5; interquartile range, 58.5-80.0) were treated by SR (25/60, 41.7%) or CA (35/60, 58.3%) as a first-line approach in 2 experienced centers. Patients' characteristics, timing, and procedural data were prospectively recorded and compared between the 2 study subgroups (regular and irregular phenotype). RESULTS: A regular phenotype at the occlusion site was observed in 24 patients (40%). Among these, successful recanalization after the first-line strategy (Thrombolysis in Cerebral Infarction 2b-3) was achieved in 100% of patients treated by CA and in only 33.3% of patients treated by SR (P=0.001). For irregular phenotypes, SR achieved Thrombolysis in Cerebral Infarction 2b-3 in 73.9% and CA, in 38.5% (P=0.036) of cases. Among regular phenotype patients, the average number of maneuvers was 1.3 (median, 1; range 1-3) with first-line CA and 2.7 (median, 3; range 1-5) with first-line SR (P=0.008). CONCLUSIONS: The angiographic phenotype of the occlusion site may be associated with a different response to SR and CA in this preliminary experience.


Assuntos
Procedimentos Endovasculares/métodos , Infarto da Artéria Cerebral Média/cirurgia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Angiografia Digital , Angiografia Cerebral , Feminino , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Fenótipo , Prognóstico , Estudos Retrospectivos , Stents
2.
Stroke ; 48(12): 3274-3281, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29089458

RESUMO

BACKGROUND AND PURPOSE: Proximal large vessel occlusion (LVO) is present in up to 30% of minor strokes. The effectiveness of mechanical thrombectomy (MT) in the subgroup of minor stroke with LVO in the anterior circulation is still open to debate. Data about MT in this subgroup of patients are sparse, and their optimal management has not yet been defined. The purpose of this multicenter cohort study was to evaluate the effectiveness of MT in patients experiencing acute ischemic stroke (AIS) because of LVO in the anterior circulation, presenting with minor-to-mild stroke symptoms (National Institutes of Health Stroke Scale score of <8). METHODS: Multicenter cohort study involving 4 comprehensive stroke centers having 2 therapeutic approaches (urgent thrombectomy associated with best medical treatment [BMT] versus BMT first and MT if worsening occurs) about management of patients with minor and mild acute ischemic stroke harboring LVO in the anterior circulation. An intention-to-treat analysis was conducted. The primary end point was the rate of excellent outcome defined as the achievement of a modified Rankin Scale score of 0 to 1 at 3 months. RESULTS: Three hundred one patients were included, 170 with urgent MT associated with BMT, and 131 with BMT alone as first-line treatment. Patients treated with MT were younger, more often received intravenous thrombolysis, and had shorter time to imaging. Twenty-four patients (18.0%) in the medical group had rescue MT because of neurological worsening. Overall, excellent outcome was achieved in 64.5% of patients, with no difference between the 2 groups. Stratified analysis according to key subgroups did not find heterogeneity in the treatment effect size. CONCLUSIONS: Minor-to-mild stroke patients with LVO achieved excellent and favorable functional outcomes at 3 months in similar proportions between urgent MT versus delayed MT associated with BMT. There is thus an urgent need for randomized trials to define the effectiveness of MT in this patient subgroup.


Assuntos
Artéria Cerebral Anterior/fisiopatologia , Arteriopatias Oclusivas/complicações , Acidente Vascular Cerebral/cirurgia , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Arteriopatias Oclusivas/tratamento farmacológico , Arteriopatias Oclusivas/fisiopatologia , Isquemia Encefálica/cirurgia , Estudos de Coortes , Determinação de Ponto Final , Feminino , Fibrinolíticos/uso terapêutico , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica , Ativador de Plasminogênio Tecidual/uso terapêutico , Resultado do Tratamento
3.
Cerebrovasc Dis ; 43(5-6): 305-312, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28384632

RESUMO

BACKGROUND: In population-based studies, patients presenting with minor or mild stroke symptoms represent about two-thirds of stroke patients, and almost one-third of these patients are unable to ambulate independently at the time of discharge. Although mechanical thrombectomy (MT) has become the standard of care for acute ischaemic stroke with proximal large vessel occlusion (LVO) in the anterior circulation, the management of patients harbouring proximal occlusion and minor-to-mild stroke symptoms has not yet been determined by recent trials. The purpose of this study was to evaluate the impact of reperfusion on clinical outcome in low National Institutes of Health Stroke Scale (NIHSS) patients treated with MT. METHODS: We analysed 138 consecutive patients with acute LVO of the anterior circulation (middle cerebral artery M1 or M2 segment, internal carotid artery or tandem occlusion) with NIHSS <8, having undergone MT in 3 different centres. Reperfusion was graded using the modified thrombolysis in cerebral infarction (TICI) score and 3 grades were defined, ranging from failed or poor reperfusion (TICI 0, 1, 2A) to complete reperfusion (TICI 3). The primary clinical endpoint was an excellent outcome defined as a modified Rankin score (mRs) 0-1 at 3-months. The impact of reperfusion grade was assessed in univariate and multivariate analyses. The secondary endpoints included favourable functional outcome (90-day mRS 0-2), death and safety concerns. RESULTS: Successful reperfusion was achieved in 81.2% of patients (TICI 2B, n = 47; TICI 3, n = 65). Excellent outcome (mRs 0-1) was achieved in 69 patients (65.0%) and favourable outcome (mRs ≤2) in 108 (78.3%). Death occurred in 7 (5.1%). Excellent outcome increased with reperfusion grades, with a rate of 34.6% in patients with failed/poor reperfusion, 61.7% in patients with TICI 2B reperfusion, and 78.5% in patients with TICI 3 reperfusion (p < 0.001). In multivariate analysis adjusted for patient characteristics associated with excellent outcome, the reperfusion grade remained significantly associated with an increase in excellent outcome; the OR (95% CI) was 3.09 (1.06-9.03) for TICI 2B and 6.66 (2.27-19.48) for TICI 3, using the failed/poor reperfusion grade as reference. Similar results were found regarding favourable outcome (90-day mRs 0-2) or overall mRS distribution (shift analysis). CONCLUSION: Successful reperfusion is strongly associated with better functional outcome among patients with proximal LVO in the anterior circulation and minor-to-mild stroke symptoms. Randomized controlled studies are mandatory to assess the benefit of MT compared with optimal medical management in this subset of patients.


Assuntos
Artéria Carótida Interna/fisiopatologia , Estenose das Carótidas/terapia , Circulação Cerebrovascular , Procedimentos Endovasculares , Infarto da Artéria Cerebral Média/terapia , Reperfusão/métodos , Trombectomia , Adulto , Idoso , Idoso de 80 Anos ou mais , Artéria Carótida Interna/diagnóstico por imagem , Estenose das Carótidas/diagnóstico por imagem , Estenose das Carótidas/mortalidade , Estenose das Carótidas/fisiopatologia , Distribuição de Qui-Quadrado , Avaliação da Deficiência , Procedimentos Endovasculares/efeitos adversos , Procedimentos Endovasculares/mortalidade , Feminino , França , Humanos , Infarto da Artéria Cerebral Média/diagnóstico por imagem , Infarto da Artéria Cerebral Média/mortalidade , Infarto da Artéria Cerebral Média/fisiopatologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Recuperação de Função Fisiológica , Sistema de Registros , Reperfusão/efeitos adversos , Reperfusão/mortalidade , Estudos Retrospectivos , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Fatores de Tempo , Resultado do Tratamento
4.
Stroke ; 48(4): 963-969, 2017 04.
Artigo em Inglês | MEDLINE | ID: mdl-28235960

RESUMO

BACKGROUND AND PURPOSE: In acute ischemic stroke patients, diffusion-weighted imaging (DWI)-Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is correlated with infarct volume and is an independent factor of functional outcome. Patients with pretreatment DWI-ASPECTS ≤6 were excluded or under-represented in the recent randomized mechanical thrombectomy trials. Our aim was to assess the impact of reperfusion in pretreatment DWI-ASPECTS ≤6 patients treated with mechanical thrombectomy. METHODS: We analyzed data collected between January 2012 and August 2015 in a bicentric prospective clinical registry of consecutive acute ischemic stroke patients treated with mechanical thrombectomy. Every patient with a documented internal carotid artery or middle cerebral artery occlusion with pretreatment DWI-ASPECTS ≤6 was eligible for this study. The primary end point was a favorable outcome defined by a modified Rankin Scale score ≤2 at 90 days. RESULTS: Two hundred and eighteen patients with a DWI-ASPECTS ≤6 were included. Among them, 145 (66%) patients had successful reperfusion at the end of mechanical thrombectomy. Reperfused patients had an increased rate of favorable outcome (38.7% versus 17.4%; P=0.002) and a decreased rate of mortality at 3 months (22.5% versus 39.1%; P=0.013) compared with nonreperfused patients. The symptomatic intracranial hemorrhage rate was not different between the 2 groups (13.0% versus 14.1%; P=0.83). However, in patients with DWI-ASPECTS <5, favorable outcome was low (13.0% versus 9.5%; P=0.68) with a high mortality rate (45.7% versus 57.1%; P=0.38) with or without successful reperfusion. CONCLUSIONS: Successful reperfusion is associated with reduced mortality and disability in patients with a pretreatment DWI-ASPECTS ≤6. Further data from randomized studies are needed, particularly in patients with DWI-ASPECTS <5.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/cirurgia , Trombólise Mecânica/métodos , Avaliação de Resultados em Cuidados de Saúde , Sistema de Registros , Reperfusão/métodos , Índice de Gravidade de Doença , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/mortalidade , Imagem de Difusão por Ressonância Magnética , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/mortalidade , Tomografia Computadorizada por Raios X
5.
Int J Stroke ; 12(4): 421-424, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-28093965

RESUMO

Background Occult atrial fibrillation (AF) may, in part, explain cryptogenic stroke. A 22% prevalence of subdiaphragmatic visceral infarction (SDVI) among patients with ischemic stroke (IS) due to AF has been reported, using abdominal MRI. We sought to assess the reproducibility of this method and to confirm that SDVI is more prevalent in cases of AF-caused IS than in IS of other etiologies. Methods In consecutive patients admitted to our hospital, we compared SDVI prevalence in three groups: patients with IS due to AF (IS+/AF+ group), patients with stroke of another determined cause (IS+/AF- group) and patients with AF without stroke (IS-/AF+ group). Results A total of 111 patients were included. The median time between inclusion and abdominal MRI was six days. SDVI was more frequent in the IS+/AF+ group ( n = 10; 21.3%), than in IS+/AF- ( n = 1; 3.3%) and IS-/AF+ ( n = 0) groups, p = 0.002. The most frequent localization was the kidney. Conclusions The prevalence of SDVI was higher among patients with AF-caused IS. In cases of cryptogenic stroke, a positive abdominal MRI may suggest occult AF as the cause and identify a high risk of AF in this subgroup of patients.


Assuntos
Fibrilação Atrial/complicações , Ataque Isquêmico Transitório/epidemiologia , Acidente Vascular Cerebral/complicações , Idoso , Feminino , Humanos , Ataque Isquêmico Transitório/etiologia , Masculino , Pessoa de Meia-Idade , Prevalência , Reprodutibilidade dos Testes , Fatores de Risco , Acidente Vascular Cerebral/terapia , Fatores de Tempo
6.
Eur Neurol ; 74(1-2): 69-72, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-26228469

RESUMO

BACKGROUND: Paradoxical embolism via a patent foramen ovale (PFO) has been suggested as a potential stroke mechanism. Combined CT venography and pulmonary angiography (CVPA) is a simple, validated and accurate technique to diagnose deep venous thrombosis (DVT) or pulmonary embolism (PE). We sought to assess the prevalence of DVT or PE among patients with PFO and cryptogenic stroke (CS) by CVPA. METHODS: Patients were identified retrospectively from a clinical registry of consecutive patients with stroke admitted to our Stroke Unit. The following criteria were required for inclusion in this study: CS, PFO identified by transthoracic echography using contrast medium and CVPA performed during the hospitalization following stroke. RESULTS: A total of 114 patients with PFO underwent a CVPA within 7 days (interquartile range 4-9) from stroke symptom onset. On cerebral imaging, 11% had multiple infarcts. CVPA documented deep vein thrombosis (DVT) in 10 patients (8.8%) and PE in 5 patients (4.4%), that is, a total of 12 patients with prevalence of 10.5% (95% CI 5.5-17.7). Patients with PE-DVT had higher D-dimers and C reactive protein level than patients without PE-DVT (p < 0.05). CONCLUSION: CVPA may be used by the stroke team in the work-up of suspected paradoxical embolism among cryptogenic ischemic stroke patients with PFO.


Assuntos
Embolia Paradoxal/diagnóstico por imagem , Forame Oval Patente/complicações , Embolia Pulmonar/diagnóstico por imagem , Acidente Vascular Cerebral/etiologia , Trombose Venosa/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , Angiografia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Flebografia/métodos , Prevalência , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Tomografia Computadorizada por Raios X/métodos
7.
J Stroke Cerebrovasc Dis ; 24(5): 952-7, 2015 May.
Artigo em Inglês | MEDLINE | ID: mdl-25804567

RESUMO

BACKGROUND: In acute ischemic stroke (AIS), bridging therapy, including intravenous thrombolysis (IVT) and mechanical thrombectomy (MET), appears to be very promising. However, data on the impact of IVT before the endovascular procedure are limited. METHODS: To examine the impact of IVT on the MET procedure, we compared the duration of this procedure, number of passes, recanalization rate, safety issues, and outcome in consecutively recruited patients either eligible for MET alone (intravenous fibrinolysis contraindication) or receiving MET preceded by IVT for proximal middle cerebral artery (MCA) occlusion within 6 hours of stroke onset. RESULTS: From January 2011 to June 2013, 68 cases with proximal MCA occlusion were available for analysis (MET alone, 40; IVT + MET, 28). The 2 groups did not differ significantly in baseline characteristics. The median National Institutes of Health Stroke Scale score at admission was 15 (10-20) for MET and 18 (13-19) for IVT + MET groups, respectively (P = .39). The median duration of the endovascular procedure (from groin puncture to recanalization) was significantly shorter in the IVT + MET group compared with that in MET alone (35 minutes [21-60] versus 60 minutes [25-91]; P = .043). The number of passes of the thrombectomy device per patient tended to be lower in the IVT + MET group than those in the MET group (P = .080). The IVT + MET group also had a higher rate of complete recanalization and a better outcome at 3 months. CONCLUSIONS: Prior IVT may facilitate the MET procedure. Further studies on MET in AIS should assess the direct impact of IVT on the endovascular procedure.


Assuntos
Fibrinolíticos/administração & dosagem , Acidente Vascular Cerebral/terapia , Trombectomia/métodos , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Feminino , Humanos , Infusões Intravenosas/métodos , Isquemia/complicações , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Estatísticas não Paramétricas , Acidente Vascular Cerebral/etiologia , Resultado do Tratamento
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