ACUTE STROKE TREATMENT IN LARGE NIHSS PATIENTS Justin Nolte, MD Assistant Profession Marshall University School of Medicine
History of Presenting Illness 64 yo wf with PMHx of COPD, HTN, HLP who was in her USOH on 8/6/14 when she developed R sided weakness and speech difficulties at 1615 who was taken to OSH where she was recognized as a likely stroke. Her labs were unrevealing and when her HCT was read as no acute changes CHH was notified and on call neuro agreed with IV tpa and given the likelihood of LM1 occlusion and recommended she be airlifted to CHH for CTA and consideration of IAT. Initial BP was 188/112 NIHSS at OSH was reportedly 23
To Treat or Not to Treat? Last Known Normal was <65 minutes Elevated BP High NIHSS What is the likelihood of recanalization with IV tpa compared with intra-arterial thrombectomy? Risks with drip and ship?
Exam Upon Arrival to Stroke Center Pulse 128 and irregularly irregular, BP 209/144, RR 20, O2 sats 91% on 2LNC NIHSS 21 consistent with LMCA syndrome including mute speech, ability to close eyes only, R hemiplegia, gaze deviation, hemianopsia, etc What needs to be done first? Cr from OSH was 2.3 by the way CTA?
Risk kidneys for CTA? Given exam suggestive of persistent proximal M1 occlusion or more proximal decision was made to pursue CTA in case she may be an IAT candidate given the lack of apparent efficacy of IV tpa in recanalization IVF hydration started and discussed plan of care with emergency contact
Repeat HCT (arrival to CHH)
Repeat HCT (day 2)
Initial HCT
Initial HCT (2)
Now What? Patient has acute embolic stroke so body was attempting to auto-anticoagulate Then we gave tpa attempting to dissolve likely embolic thrombus Is reversing tpa in a patient with acute stroke safe? (1) 40% pts ICH worsened after it was identified No thrombotic complications were identified What should be used to reverse tpa if so? (2) 1. Goldstein, et al. Management of Thrombolysis-Associated Symptomatic Intracerebral Hemorrhage. Archives of Neurology. Aug 2010; 67(8): 965-969. 2. Broderick, et al. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage in Adults. Stroke. 2007; 38: 2001-2023
How d she do? OSH presenting NIHSS 23 NIHSS on presentation to CHH 21 Discharge NIHSS 9 (1 facial droop, 1 gaze pref, 1 slurred speech, 3 for RUE and 3 RLE weakness) Speech was mostly fluent with significant spoken and receptive issues Despite her large NIHSS, multiple comorbidities, significant previous small vessel ischemic changes, HI after IV tpa, Kcentra she beat the odds. Obviously can t generalize care based on personal experience of one patient
Significance of ICH after Recanalization Hemorrhagic Transformation (HI/T) vs Parenchymal Hematoma (PH) NINDS definitions HI: acute infarction with punctate or variable hypodensity/hyperdensity, with an indistinct border within the vascular territory PH: typical homogeneous, hyperdense lesion with a sharp border with or without edema or mass effect ECASS (1 and 2) definitions HI: petechial infarction without space-occupying effect HI1: small petechiae HI2: more confluent petechiae PH: hemorrhage (coagulum) with mass effect PH1: <30% of the infarcted area with mild space-occupying effect effect PH2: >30% of the infarcted area with significant space-occupying Trouillas, et al. Classification and Pathogenesis of Cerebral Hemorrhages After Thrombolysis in Ischemic Stroke. Stroke. 2006; 37: 556-561
Significance of ICH after Recanalization PH correlated with worsened outcome and morbidity but HT was not (1) +/- tpa: HT1/HT2 and PH1 were NOT predictive of worsened early neurologic worsening, mortality or morbidity but PH2 was (morbidity was not statistically different at 3 months) (2) 1. Paciaroni, et al. Early Hemorrhagic Transformation of Brain Infarction: Rate, Predictive Factors, and Influence on Clinical Outcome. Stroke. 2008; 39: 2249-2256. 2. Fiorelli, et al. Hemorrhagic Transformation Within 36 Hours of a Cerebral Infarct Relationships With Early Clinical Deterioration and 3-Month Outcome in the European Cooperative Acute Stroke Study I (ECASS I) Cohort. Stroke. 1999; 30: 2280-2284
Would you have treated?
Current Relative Contraindications In addition to the contraindications, the risks of Activase therapy may be increased in the following conditions and should be weighed against the anticipated benefits Severe neurological deficit (eg, National Institutes of Health Stroke Scale [NIHSS] >22 at presentation) Major early infarct signs by an imaging technique (eg, substantial edema, mass effect, or midline shift) www.activase.com
Natural History of Large Artery Occlusions 120 patients (13 with TICA lesions, 69 prox M1 and 38 distal M1 occlusions) mrs >2 = poor prognosis 92%, 87% and 47% respectively - p<0.001 Death at 3 months TICA (23%, 12% and 3% respectively) p=0.001 Hernandez-Perez, et al. Natural history of acute stroke due to occlusion of the middle cerebral artery and intracranial internal carotid artery. J Neuroimaging. 2014 Jul-Aug;24(4):354-8.
Natural History of Large Artery Occlusions 126 patients with a unilateral complete occlusion of the intracranial internal carotid artery (ICA; 26 patients: median National Institutes of Health Stroke Scale [NIHSS] score, 11 [interquartile range, 5-17]), of the M1 segment of the middle cerebral artery (MCA; 52 patients: median NIHSS score, 13 [interquartile range, 6-16]), or of the M2 segment of the MCA (48 patients: median NIHSS score, 7 [interquartile range, 4-15]) were included. Of these 3 groups of patients, 10 (38.5%), 20 (38.5%), and 26 (54.2%) with ICA, MCA-M1, and MCA-M2 occlusions, respectively, achieved a modified Rankin Scale score of 2 or less 6 (23.1%), 12 (23.1%), and 10 (20.8%) were dead at 6 months. the level of proximal intracranial arterial occlusion (ICA vs MCA-M1 vs MCA-M2) was not predictive of outcome Lima, et al. Prognosis of untreated strokes due to anterior circulation proximal intracranial arterial occlusions detected by use of computed tomography angiography. JAMA Neurol. 2014 Feb;71(2):151-7.
Recanalization Rates for IV tpa Among 1341 patients in the CT angiogram database, 388 patients with proximal occlusion were identified. Of these, 216 patients had received IV rt-pa; 127 patients underwent further imaging to assess recanalization. Among the patients undergoing TCD (n=46) and cerebral angiogram (n=103), only 27 (21.25%) patients had acute recanalization. By occlusion subtype, the rates of recanalization were: distal ICA - 1 of 24 (4.4%) M1-MCA - 21 of 65 (32.3%) M2-MCA 4 of 13 (30.8%) basilar artery 1 of 25 (4%). Onset to rt-pa time was comparable in patients with and without recanalization. Recanalization (P<0.0001; risk ratio, 2.7; 95% confidence interval, 1.5-4.6) was the strongest predictor of outcome (adjusted for age and National Institutes of Health Stroke Scale score). Bhatia, et al. Low rates of acute recanalization with intravenous recombinant tissue plasminogen activator in ischemic stroke: real-world experience and a call for action. Stroke. 2010 Oct;41(10):2254-8
Recanalization Rates for IAT 104 consecutive patient s who went for mechanical thrombectomy were included, of which 26 had intracranial carotid artery occlusion. Successful recanalization was achieved in 77% (20/26) of patients Recanalization was achieved with the Solitaire stent alone in 69% (18/26) of patients. Ten patients (39%) had a good clinical outcome (mrs score of 0-2) at 3 months. There was a good outcome in 50% of patients (10/20) with recanalization and no good outcome in patients (0/6) without recanalization (P = 0.027). No symptomatic intracerebral hemorrhage occurred. Mortality was 8% (2/26) at 3 months. Yoon, et al. Outcome of mechanical thrombectomy with Solitaire stent as first-line intra-arterial treatment in intracranial internal carotid artery occlusion. Neuroradiology. 2013 Aug;55(8):999-1005
Recanalization Rate of IVtPA + IAT? Fifty patients with intra-arterial occlusion (VAGUE) (mean age, 66.8 y ± 14.6) had a baseline median NIHSS score of 18.0. Overall recanalization was achieved in 94% of patients, and complete recanalization (ie, TICI 3 flow) was achieved in 72% of patients. The mean time from stroke onset to maximal recanalization was 244.2 minutes ± 87.9, with a median of 232.5 minutes. The average number of device passes was 1.5, with a mean procedure time to maximal recanalization of 49.5 minutes ± 13.0. Symptomatic intracerebral hemorrhage occurred in 6% of patients. The median mrs score at 90 days was 1 60% of patients had a good outcome (ie, mrs score 0-2). The overall 3-month mortality rate was 14%. Sanak, et al. Acute combined revascularization in acute ischemic stroke with intracranial arterial occlusion: self-expanding solitaire stent during intravenous thrombolysis. J Vasc Interv Radiol. 2013 Sep;24(9):1273-9
Would you treat now?
Thanks!