Minor stroke due to large artery occlusion. When is intravenous thrombolysis not enough? Results from the SITS International Stroke Thrombolysis Register

Abstract

on behalf of SITS InvestigatorsAbstract Purpose: Beyond intravenous thrombolysis, evidence is lacking on acute treatment of minor stroke caused by large artery occlusion. To identify candidates for additional endovascular therapy, we aimed to determine the frequency of non-haemorrhagic early neurological deterioration in patients with intravenous thrombolysis-treated minor stroke caused by occlusion of large proximal and distal cerebral arteries. Secondary aims were to establish risk factors for non-haemorrhagic early neurological deterioration and report three-month outcomes in patients with and without nonhaemorrhagic early neurological deterioration. Method: We analysed data from the SITS International Stroke Thrombolysis Register on 2553 patients with intravenous thrombolysis-treated minor stroke (NIH Stroke Scale scores 0-5) and available arterial occlusion data. Non-haemorrhagic early neurological deterioration was defined as an increase in NIH Stroke Scale score 4 at 24 h, without parenchymal hematoma on follow-up imaging within 22-36 h. Findings: The highest frequency of non-haemorrhagic early neurological deterioration was seen in 30% of patients with terminal internal carotid artery or tandem occlusions (internal carotid artery þ middle cerebral artery) (adjusted odds ratio: 10.3 (95% CI 4.3-24.9), p < 0.001) and 17% in extracranial carotid occlusions (adjusted odds ratio 4.3 (2.5-7.7), p < 0.001) versus 3.1% in those with no occlusion. Proximal middle cerebral artery-M1 occlusions had non-haemorrhagic early neurological deterioration in 9% (adjusted odds ratio 2.1 (0.97-4.4), p ¼ 0.06). Among patients with any occlusion and non-haemorrhagic early neurological deterioration, 77% were dead or dependent at three months. Conclusions: Patients with minor stroke caused by internal carotid artery occlusion, with or without tandem middle cerebral artery involvement, are at high risk of disabling deterioration, despite intravenous thrombolysis treatment. Acute vessel imaging contributes usefully even in minor stroke to identify and consider endovascular treatment, or intensive monitoring at a comprehensive stroke centre, for patients at high risk of neurological deterioration.

Acute in‐hospital blood pressure variability predicts early neurological deterioration in acute minor stroke or transient ischemic attack with steno‐occlusive arterial disease

“…To prove the association of BPV and END, we adopted a definition of END as a ≥1‐point increase in NIHSS score during the first 72 hours after admission. And, the rate of END was 32.5% in this study, which was consistent with the rates in previous studies . And also, our findings were similar to that in the Chungs' study .…”

“…And, the rate of END was 32.5% in this study, which was consistent with the rates in previous studies. [4][5][6][7][8][9][10] And also, our findings were similar to that in the Chungs' study. 16 Both studies suggested that the acute in-hospital BPV was strongly associated with the risk of having a END.…”

“…It is reported that minor ischemic stroke and TIA account for ≈65% of all acute ischemic cerebrovascular events . Although minor stroke and TIA seem to be benign, recent studies have shown that a significant proportion of patients with steno‐occlusive arterial disease is in unstable clinical state and has high risks of recurrent cerebrovascular events or early neurological deterioration (END) in the hospital, resulting in major physical disability . Therefore, it is of great importance to identify factors associated with END in patients with acute minor stroke or TIA due to steno‐occlusive arterial disease.…”

Impact of Transcranial Doppler Ultrasound on Logistics and Outcomes in Stroke Thrombolysis

“…Also, during the study period, anatomic data on the location of arterial occlusion was not recorded in SITS, contrary to more recent years. 21 Still, during the study period, IVT was a well-established therapy, and acute diagnostic TCD was implemented across a wide range of hospitals in Europe and beyond. A further limitation of our data set, the lack of specific time points for the performance of CTA or MRA, precludes us from comparing logistics and outcomes in patients undergoing TCD versus CTA/MRA.…”

Reperfusion therapy for minor stroke: A systematic review and meta‐analysis

“…The reason for excluding minor stroke from IV rt-PA trails might be that thrombolysis could increase the risk of ICH and the benefit of IV rt-PA within these patients is unclear so far. Several retrospective studies indicated that IV rt-PA was effective for acute minor stroke (Förster, 2011;Laurencin et al, 2015;Mazya, 2017;Meyer, Lavados, & Olavarria, 2016;Mittal, Rymer, & Lai, 2011), but lack of evidence from well-designed randomized controlled trials (RCTs). Several retrospective studies indicated that IV rt-PA was effective for acute minor stroke (Förster, 2011;Laurencin et al, 2015;Mazya, 2017;Meyer, Lavados, & Olavarria, 2016;Mittal, Rymer, & Lai, 2011), but lack of evidence from well-designed randomized controlled trials (RCTs).…”