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  • 1
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    Is Intra-Arterial Thrombolysis Safe After Full-Dose Intravenous Recombinant Tissue Plasminogen Activator for Acute Ischemic Stroke?
    Ovid Technologies (Wolters Kluwer Health) ; 2007
    In:  Stroke Vol. 38, No. 1 ( 2007-01), p. 80-84
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 38, No. 1 ( 2007-01), p. 80-84
    Abstract: Background and Purpose— The optimal approach for acute ischemic stroke patients who do not respond to intravenous recombinant tissue plasminogen activator (IV rt-PA) is uncertain. This study evaluated the safety and response to intra-arterial thrombolytics (IATs) in patients unresponsive to full-dose IV rt-PA. Methods— A case series from a prospectively collected database on consecutive acute ischemic stroke patients treated with IATs after 0.9 mg/kg IV rt-PA during a 7-year interval was collected. Primary outcome measures included symptomatic intracranial hemorrhage and mortality. As indicators of response, secondary outcome measures were recanalization and discharge disposition. Results— Sixty-nine patients (mean±SD age, 60±13 years; range, 26 to 85 years; 55% male) with a median pretreatment National Institutes of Health Stroke Scale score of 18 (range, 6 to 39) were included. IV rt-PA was started at 124±32 minutes (median, 120 minutes) and IAT, at 288±57 minutes (median, 285 minutes). IATs consisted of reteplase (n=56), alteplase (n=7), and urokinase (n=6), with an average total dosage of 2.8 U, 8.6 mg, and 700 000 U, respectively. Symptomatic intracranial hemorrhage occurred in 4 of 69 (5.8%) patients; 3 cases were fatal. Recanalization was achieved in 50 (72.5%) and a favorable outcome (home or inpatient rehabilitation) in 38 (55%). Conclusions— IAT therapy after full-dose IV rt-PA in patients with persisting occlusion and/or lack of clinical improvement appears safe compared with IV rt-PA alone or low-dose IV rt-PA followed by IAT. A high rate of recanalization and favorable outcome can be achieved.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/01.STR.0000251720.25337.b0
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2007
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  • 2
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    Argatroban tPA Stroke Study : Study Design and Results in the First Treated Cohort
    American Medical Association (AMA) ; 2006
    In:  Archives of Neurology Vol. 63, No. 8 ( 2006-08-01), p. 1057-
    Details
    In: Archives of Neurology, American Medical Association (AMA), Vol. 63, No. 8 ( 2006-08-01), p. 1057-
    Type of Medium: Online Resource
    ISSN: 0003-9942
    URL: Article
    DOI: 10.1001/archneur.63.8.1057
    RVK:
    XA 10000
    Language: English
    Publisher: American Medical Association (AMA)
    Publication Date: 2006
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  • 3
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    Abstract 187: Impact of General Anesthesia on Safety and Outcomes in the Endovascular Arm of IMS III
    Ovid Technologies (Wolters Kluwer Health) ; 2014
    In:  Stroke Vol. 45, No. suppl_1 ( 2014-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 45, No. suppl_1 ( 2014-02)
    Abstract: Objectives: Use of general anesthesia (GA) during endovascular therapy (ET) of AIS patients is controversial with some suggestion of worse outcomes and death. The IMS III trial permitted the study of the effect of GA in a prospectively collected data set to test two hypotheses: (1) intubation is associated with poorer outcomes and (2) there is no increase in the risk of SAH or sICH with local anesthesia (LA). Methods: IMS III was a randomized trial of IV tPA +/- ET in patients presenting within 3hrs of AIS onset. In addition to demographic and outcomes data (mRS, ICH, etc.), information was collected on GA use or not within 7hrs of stroke onset. A good outcome was defined as mRS≤2 at 90 days. A multivariable analysis adjusting for dichotomized NIHSS (8-19 vs. ≥20), age and time from onset to groin puncture was performed. Additional analyses of reasons for intubation are ongoing and will be part of the presentation. Results: Four-hundred-thirty-four patients were randomized to ET, 269(62%) with LA and 147(33.9%) with GA. They were evenly matched in demographics, medical comorbidities, time to tPA, time to groin puncture, 40minute post IV tPA bolus SBP and occlusion location/side. The baseline NIHSS were slightly lower in the LA group (median 16 vs. 18). The GA group was less likely to achieve a good outcome (RR 0.64, CI 0.49-0.84, p=0.001) and had a greater risk of in-hospital death (RR 3.11, CI 1.86-5.20, p 〈 0.0001). There was an increased risk of SAH in the GA group (RR 1.79, CI 1.04-3.08, p=0.0364) but no statistically significant difference in sICH (RR 1.69, CI 0.79-3.61, p=0.18). The multivariable analysis confirmed the negative association between GA and good outcomes (RR 0.68, CI 0.52-0.90, p=0.0027). Conclusions: In the IMS III trial there was an association with worse neurological outcomes and increased mortality with ET under GA. Also, there was an association between GA and an increased risk of SAH. Although the reasons for these associations are not clear, these data support the use of LA when possible during ET.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.45.suppl_1.187
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2014
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  • 4
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    Collaterals at Angiography and Outcomes in the Interventional Management of Stroke (IMS) III Trial
    Ovid Technologies (Wolters Kluwer Health) ; 2014
    In:  Stroke Vol. 45, No. 3 ( 2014-03), p. 759-764
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 45, No. 3 ( 2014-03), p. 759-764
    Abstract: Endovascular strategies provide unique opportunity to correlate angiographic measures of collateral circulation at the time of endovascular therapy. We conducted systematic analyses of collaterals at conventional angiography on recanalization, reperfusion, and clinical outcomes in the endovascular treatment arm of the Interventional Management of Stroke (IMS) III trial. Methods— Prospective evaluation of angiographic collaterals was conducted via central review of subjects treated with endovascular therapy in IMS III (n=331). Collateral grade before endovascular therapy was assessed with the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale, blinded to all other data. Statistical analyses investigated the association between collaterals with baseline clinical variables, angiographic measures of recanalization, reperfusion and clinical outcomes. Results— Adequate views of collateral circulation to the ischemic territory were available in 276 of 331 (83%) subjects. Collateral grade was strongly related to both recanalization of the occluded arterial segment ( P =0.0016) and downstream reperfusion ( P 〈 0.0001). Multivariable analyses confirmed that robust angiographic collateral grade was a significant predictor of good clinical outcome (modified Rankin Scale score ≤2) at 90 days ( P =0.0353), adjusted for age, history of diabetes mellitus, National Institutes of Health Stroke Scale strata, and Alberta Stroke Program Early CT Score. The relationship between collateral flow and clinical outcome may depend on the degree of reperfusion. Conclusions— More robust collateral grade was associated with better recanalization, reperfusion, and subsequent better clinical outcomes. These data, from the largest endovascular trial to date, suggest that collaterals are an important consideration in future trial design. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00359424.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.113.004072
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2014
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  • 5
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    Online Resource
    The Argatroban and Tissue-Type Plasminogen Activator Stroke Study : Final Results of a Pilot Safety Study
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  Stroke Vol. 43, No. 3 ( 2012-03), p. 770-775
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 43, No. 3 ( 2012-03), p. 770-775
    Abstract: Argatroban is a direct thrombin inhibitor that safely augments recanalization achieved by tissue-type plasminogen activator (tPA) in animal stroke models. The Argatroban tPA Stroke Study was an open-label, pilot safety study of tPA plus Argatroban in patients with ischemic stroke due to proximal intracranial occlusion. Methods— During standard-dose intravenous tPA, a 100-μg/kg bolus of Argatroban and infusion for 48 hours was adjusted to a target partial thromboplastin time of 1.75× baseline. The primary outcome was incidence of significant intracerebral hemorrhage defined as either symptomatic intracerebral hemorrhage or Parenchymal Hematoma Type 2. Recanalization was measured at 2 and 24 hours by transcranial Doppler or CT angiography. Results— Sixty-five patients were enrolled (45% men, mean age 63±14 years, median National Institutes of Health Stroke Scale=13). The median (interquartile range) time tPA to Argatroban bolus was 51 (38–60) minutes. Target anticoagulation was reached at a median (interquartile range) of 3 (2–7) hours. Significant intracerebral hemorrhage occurred in 4 patients (6.2%; 95% CI, 1.7–15.0). Of these, 3 were symptomatic (4.6%; 95% CI, 0.9–12.9). Seven patients (10%) died in the first 7 days. Within the 2-hour monitoring period, transcranial Doppler recanalization (n=47) occurred in 29 (61%) patients: complete in 19 (40%) and partial in another 10 (21%). Conclusions— The combination of Argatroban and intravenous tPA is potentially safe in patients with moderate neurological deficits due to proximal intracranial arterial occlusions and may produce more complete recanalization than tPA alone. Continued evaluation of this treatment combination is warranted. Clinical Trial Registration— URL: www.clinicaltrials.gov . Unique identifier: NCT00268762.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.111.625574
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
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  • 6
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    Abstract 158: Rescue Strategy for Failed Mechanical Thrombectomy in Acute Ischemic Stroke: An Analysis of the SVIN Registry
    Ovid Technologies (Wolters Kluwer Health) ; 2024
    In:  Stroke Vol. 55, No. Suppl_1 ( 2024-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 55, No. Suppl_1 ( 2024-02)
    Abstract: Background: Mechanical thrombectomy (MT) fails to achieve successful reperfusion in up to 20% of large vessel occlusions (LVOs). Rescue strategies (RS) have shown promise in multicenter studies and meta-analyses. We aimed to evaluate the association between RS with functional outcomes compared to medical management (MM) in patients who underwent failed MT. Methods: This is a cross-sectional study using prospectively collected data from the Society of Vascular and Interventional Neurology (SVIN) Registry from 2018 to 2021. We included all adult patients with anterior circulation LVOs who experienced a failed MT (mTICI 0-2a after multiple attempts to clot retrieval) at the 14 participating centers. The patients were divided into two groups: those who received RS (including balloon angioplasty alone, intracranial stenting with or without balloon angioplasty) and those who only received MM. The primary outcome was the shift in the degree of disability, as measured by the mRS at 90 days. Additional outcomes included functional independence (90-day mRS score of 0-2), sICH, and mortality at 90 days. Results: A total of 642 patients were included in the analysis. The RS group consisted of 294 (45.8%) patients, while the MM group comprised 348 (54.2%) patients. A mTICI score of 2b-3 was achieved in 242/293 (82.6%) patients in the RS group. After adjusting for confounders, the RS group showed a favorable shift in the overall 90-day mRS distribution (acOR=1.97, 95%CI 1.36-2.85, p = 〈 0.001) and higher rates of functional independence (RS: 30.7% vs. MM: 12%, aOR=2.39, 95%CI 1.34-4.26, p =0.003) ( Figure ) compared to the MM group. RS also showed lower rates of sICH (RS: 2.7% vs. MM: 9%, aOR=0.32, 95%CI 0.14-0.71, p =0.005) and 90-day mortality (RS: 29.5% vs. MM: 49.7%, aOR=0.49, 95%CI 0.33-0.74, p = 〈 0.001). Conclusion: Our findings support the use of RS as a potential alternative for stroke patients with failed MT. Further prospective studies are needed to validate these observations.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.55.suppl_1.158
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2024
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  • 7
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    A Pilot Randomized Clinical Safety Study of Sonothrombolysis Augmentation With Ultrasound-Activated Perflutren-Lipid Microspheres for Acute Ischemic Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2008
    In:  Stroke Vol. 39, No. 5 ( 2008-05), p. 1464-1469
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 39, No. 5 ( 2008-05), p. 1464-1469
    Abstract: Background and Purpose— Ultrasound transiently expands perflutren-lipid microspheres (μS), transmitting energy momentum to surrounding fluids. We report a pilot safety/feasibility study of ultrasound-activated μS with systemic tissue plasminogen activator (tPA). Methods— Stroke subjects treated within 3 hours had abnormal Thrombolysis in Brain Ischemia (TIBI) residual flow grades 0 to 3 before tPA on transcranial Doppler (TCD). Randomization included Controls (tPA+TCD) or Target (tPA+TCD+2.8 mL μS). The primary safety end point was symptomatic intracranial hemorrhage (sICH) with worsening by ≥4 NIHSS points within 72 hours. Results— Fifteen subjects were randomized 3:1 to Target, n=12 or Control, n=3. After treatment, asymptomatic ICH occurred in 3 Target and 1 Control, and sICH was not seen in any study subject. μS reached MCA occlusions in all Target subjects at velocities higher than surrounding residual red blood cell flow: 39.8±11.3 vs 28.8±13.8 cm/s, P 〈 0.001. In 75% of subjects, μS permeated to areas with no pretreatment residual flow, and in 83% residual flow velocity improved at a median of 30 minutes from start of μS infusion (range 30 s to 120 minutes) by a median of 17 cm/s (118% above pretreatment values). To provide perspective, current study recanalization rates were compared with the tPA control arm of the CLOTBUST trial: complete recanalization 50% versus 18%, partial 33% versus 33%, none 17% versus 49%, P =0.028. At 2 hours, sustained complete recanalization was 42% versus 13%, P =0.003, and NIHSS scores 0 to 3 were reached by 17% versus 8%, P =0.456. Conclusions— Perflutren μS reached and permeated beyond intracranial occlusions with no increase in sICH after systemic thrombolysis suggesting feasibility of further μS dose-escalation studies and development of drug delivery to tissues with compromised perfusion.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.107.505727
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2008
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  • 8
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    psn-5. Elective Endovascular Reconstruction of the Extracranial Arteries for Stroke Prevention.
    Southern Medical Association ; 2003
    In:  Southern Medical Journal Vol. 96, No. Supplement ( 2003-11), p. S73-
    Details
    In: Southern Medical Journal, Southern Medical Association, Vol. 96, No. Supplement ( 2003-11), p. S73-
    Type of Medium: Online Resource
    ISSN: 0038-4348
    URL: Article
    DOI: 10.1097/00007611-200311001-00221
    Language: English
    Publisher: Southern Medical Association
    Publication Date: 2003
    detail.hit.zdb_id: 2031166-7
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  • 9
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    Hypereosinophilic syndrome presenting acutely with neurologic signs
    Elsevier BV ; 2018
    In:  Annals of Allergy, Asthma & Immunology Vol. 120, No. 5 ( 2018-05), p. 461-464
    Details
    In: Annals of Allergy, Asthma & Immunology, Elsevier BV, Vol. 120, No. 5 ( 2018-05), p. 461-464
    Type of Medium: Online Resource
    ISSN: 1081-1206
    URL: Article
    DOI: 10.1016/j.anai.2018.02.032
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2018
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  • 10
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    Abstract 96: CTP-Mismatch Maps Improve Interobserver Agreement
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  Stroke Vol. 43, No. suppl_1 ( 2012-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 43, No. suppl_1 ( 2012-02)
    Abstract: Introduction: The use of mismatch between the ischemic core and penumbra to select patients who are likely to benefit from acute stroke therapy has gained popularity. Interpretation of the ischemic core and penumbra on standard CT-perfusion (CTP) maps is subjective. This may lead to variability among physicians in the decision if a patient is a good candidate for acute stroke therapy. A CTP-Mismatch map with outlines of the ischemic core and penumbra could limit this variability. The goal of this study was to determine if inter-observer agreement regarding a patient’s suitability for acute stroke therapy improves with the use of a CTP-Mismatch map. The figure shows a typical CTP-Mismatch map. Methods: Ninety-six consecutive patients evaluated with CTP prior to intra-arterial therapy at St. Lukes Hospital in 2008-09 were included. 79 patients had adequate quality CTP for this analysis. Standard CTP maps (CBV, CBF, MTT, and Tmax) and a CTP-Mismatch map were generated with a fully automated program for processing of CTP source images (RAPID). RAPID assessed the ischemic core using a CBF threshold 〈 30% of the contralateral hemisphere (rCBF 〈 30%). The ischemic penumbra was defined by a Tmax threshold of 〉 6 sec (Tmax 〉 6s). The standard CTP maps and the CTP-Mismatch map were independently analyzed by two vascular neurologists in a blinded fashion. The raters assessed a patient's suitability for intra-arterial therapy based on the following mismatch criteria: (1) a ratio between (Tmax 〉 6s) and (rCBF 〈 30%) volumes 〉 1.8 and (2) an absolute difference between (Tmax 〉 6s) and (CBF 〈 30%) volumes 〉 15ml. Interobserver reliability was assessed with Cohen’s kappa. Results: When assessment of suitability for intra-arterial therapy was based on interpretation of standard CTP maps, the two raters agreed in 58 of 79 patients (kappa=0.46; 95% CI=0.24-0.60). The agreement between observers improved when suitability was determined using CTP-Mismatch maps (agreement in 76 of 79 cases; kappa=0.92; 95% CI=0.75-0.92; p 〈 0.001 for difference between kappa values). The 3 cases with inter-observer disagreement had artifact on the CTP-Mismatch map. Following concensus adjudication of these 3 cases, 40 of the 79 patients (51%) were deemed suitable candidates for acute stroke therapy. Conclusion: CTP-Mismatch maps with estimates of ischemic core and penumbra volumes markedly improve inter-observer agreement regarding assessment of suitability for acute stroke therapy. Such maps, which can be generated automatically, may help standardize decision making algorithms for evaluation of potential intra-arterial therapy candidates.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.43.suppl_1.A96
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
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