Characteristics and Treatment Results of In-hospital Acute Ischemic Stroke due to Large Vessel Occlusion Treated by Mechanical Thrombectomy

Abstract

The purpose of this study was to investigate the characteristics, time-line, and treatment results of in-hospital acute ischemic stroke due to large vessel occlusion (LVO) treated by mechanical thrombectomy. Methods: The authors investigated 10 patients (six males and four females; mean age 78.6 years, range 65-92) with in-hospital LVO treated by thrombectomy between January 2016 and July 2018 in our institute. Patient characteristics, procedural results, clinical outcome, and time-line data of thrombectomy (last well known [LWK]/onset, recognition, arterial puncture, and recanalization) were retrospectively evaluated. Results obtained from in-hospital LVO were compared with those from 13 patients with community-onset LVO (eight males and five females; mean age 78.3 years, range 45-87). Results: The initial admitting departments of in-hospital LVO were cardiology in six (60%) and hematology, otolaryngology, urology, and gastroenterology in one each (10%). The etiologies of ischemic stroke were cardioembolism in eight (80%), thrombosis in one (10%), and iatrogenic consequence in one (10%). The comorbid disease of in-hospital LVO included cardiac disease in eight (80%) and malignant tumor in four (40%) with overlapping. The factor contributing to in-hospital LVO was invasive procedure with withdrawal of antithrombotic agents in three (30%). The interval between LWK and recognition was a median of 60 minutes in in-hospital LVO, which was shorter than LWK-to-arrival time in communityonset LVO (medial 225 minutes). The interval between recognition and consultation to the neuroendovascular team was a median of 50 minutes. The recognition-to-puncture time was compared with arrival-to-puncture time in communityonset LVO. That presented no difference between them (median 130 vs 150 minutes). The LWK-to-recanalization time in in-hospital LVO was shorter than that in community-onset LVO (median 240 vs 495 minutes). The procedural results of thrombectomy demonstrated no differences between them. The rate of thrombolysis in cerebral infarction (TICI) 2b-3 was 70% in in-hospital vs 85% in community-onset LVO. The rate of favorable outcome (modified Rankin Scale [mRS] 0-2) at discharge was not different (30% vs 23%); however, higher rates of mortality and severe disability (mRS 5-6) were observed in patients with in-hospital LVO compared to those with community-onset LVO (40% vs 15%). Conclusion: In this series, the procedural results of thrombectomy were not different between in-hospital and communityonset LVO. The recognition-to-puncture time in in-hospital LVO was similar to the arrival-to-puncture time in community-onset LVO, although the LWK-to-recognition/recanalization time in in-hospital LVO was shorter compared with the LWK-toarrival/recanalization-time in community-onset LVO. The rate of clinical favorable outcome was similar, although a higher rate of poor outcome was observed in in-hospital LVO. Comorbid diseases may be associated with poor outcome in in-hospital ischemic stroke due to LVO.

Other Hospital-onset Acute Ischemic Stroke Due to Large Vessel Occlusion Treated by Mechanical Thrombectomy after Inter-hospital Transfer

“…Previous studies have reported high mortality and low rates of discharge to home following thrombectomy for patients who develop LVO in-hospital compared to those who develop it in the community. 2,[4][5][6] In this series, the rates of both mRS 5-6 and mRS 0-2 at discharge were a little higher in the own hospital-onset patients than in the other two groups. As mentioned earlier, the increased interest and understanding of emergency stroke management may have helped improve the outcomes of patients who develop in-hospital LVO, especially in comprehensive stroke centers or thrombectomy-capable stroke centers.…”

“…Acute stroke due to LVO commonly arises in patients in the community, but LVO can also develop at medical facilities during hospitalization. [2][3][4][5][6] Mechanical Neurologia medico-chirurgica Advance Publication Date: March 5, 2020 hospital that does not provide thrombectomy, additional time is required for the inter-hospital transfer.…”

Mechanical Thrombectomy for In-Hospital Onset Stroke: A Comparative Systematic Review and Meta-Analysis

“…Mechanical thrombectomy has also been established as a safe procedure for patients with IHOS in terms of sICH and other procedure-related complications, even in critically ill patients with a higher antithrombotic therapy burden [ 1 , 3 , 18 ]. Several studies have reported that the incidence of periprocedural complications was not significantly higher in IHOS patients compared to patients with COS, and the occurrence of sICHs was evenly distributed between the two groups [ 1 - 5 , 18 - 20 ]. Our meta-analysis also verified these results.…”

“…While randomized clinical trials have investigated the impact of mechanical thrombectomy on the outcomes of patients with acute ischemic stroke, these studies have primarily focused on patients who present to the emergency department from the community setting and follow specific treatment pathways for stroke. However, a notable proportion of all strokes occur in hospitalized patients, who may not be included in specific protocols for acute ischemic stroke management [ 3 , 5 ]. Moreover, these patients differ from the general population because they carry concurrent acute medical conditions requiring a hospital stay and are more often ineligible to receive intravenous thrombolysis [ 3 , 6 ].…”

Status of In-Hospital Acute Ischemic Stroke Treated by Mechanical Thrombectomy

“…In Japan, similar results were also reported. 5 , 6) This is because arrhythmia, including atrial fibrillation, ischemic heart disease, and heart failure, which cause cardiogenic cerebral infarction, are treated in the cardiology department. Furthermore, stroke onset was reported in approximately 1% of inpatients with myocardial infarction.…”