Clinical Management of Acute Ischemic Stroke

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Clinical Neurology".

Deadline for manuscript submissions: closed (25 February 2024) | Viewed by 5100

Special Issue Editors

Stroke Unit and Clinical Neurology, Department of Neuroscience, Udine University Hospital, Udine, Italy.
Interests: stroke; thrombolysis; thrombectomy; post-stroke epilepsy
Neurology Unit, Stroke Unit, Department of Neuromotor Physiology and Rehabilitation, Azienda Unità Sanitaria Locale – IRCCS di Reggio Emilia, Reggio Emilia, Italy
Interests: stroke; neuroimaging; neurointerventional; angiography; rare neurovascular disorders; small vessel disease
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Special Issue Information

Dear Colleagues,

Stroke is the second leading cause of death and a major cause of disability worldwide. Although recanalization therapy has changed the outcome for patients with acute ischemic stroke during the last decades, several issues remain unresolved and vascular neurology/neuroradiologists still wait for answers. Tenecteplase is a next-generation genetically modified rtPA and is currently the most promising alternative agent to alteplase. However, more data are needed and current European Stroke Organization guidelines for patients with AIS of < 4.5 hours duration who are not eligible for MT suggest intravenous thrombolysis with alteplase over tenecteplase. The best medical treatment for minor, non-disabling, ischemic stroke is yet unknown. Several patients with acute ischemic stroke due to large vessel occlusion can develop “futile” recanalization, i.e., a poor clinical outcome despite a successful recanalization of the occluded vessel. Mechanisms and predictors of “futile” recanalization remain largely unrecognized and deserve further evaluation. Moreover, the balance between benefit and harm in the selection of the patients for i.v. or endovascular reperfusion is still hard to assess in individual cases because of the presence of several grey areas (e.g., field and meaning of perfusion studies vs. collateral status evaluation, pure hemodynamic stroke in the setting of chronic large vessel occlusions, multiple simultaneous vessel occlusions, the opportunity to tailor the treatment to the cause of the stroke and not only to the site of vessel occlusion, etc.). Epileptic status after acute ischemic stroke represents an uncommon, but harmful, consequence. Little is known about the outcome of these patients in terms of disability and mortality. These issues, and many others, will be covered by review papers, clinical, and experimental studies in this Special Issue of the Journal of Clinical Medicine focused on the clinical management of acute ischemic stroke.

Dr. Giovanni Merlino
Dr. Maria Luisa Zedde
Guest Editors

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Keywords

  • thrombolysis
  • thrombectomy
  • non-disabling ischemic stroke
  • futile recanalization
  • post-stroke epileptic status
  • perfusion
  • penumbra
  • hemodynamic stroke
  • intracranial stenosis
 

Published Papers (4 papers)

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Research

18 pages, 2990 KiB  
Article
Inter-Rater Reliability of Collateral Status Assessment Based on CT Angiography: A Retrospective Study of Middle Cerebral Artery Ischaemic Stroke
J. Clin. Med. 2023, 12(17), 5470; https://doi.org/10.3390/jcm12175470 - 23 Aug 2023
Viewed by 785
Abstract
The importance of assessing the collateral status (CS) in patients with ischaemic stroke (IS) has repeatedly been emphasised in clinical guidelines. Various publications offer qualitative or semiquantitative scales with gradations corresponding to the different extents of the collaterals, visualised mostly on the basis [...] Read more.
The importance of assessing the collateral status (CS) in patients with ischaemic stroke (IS) has repeatedly been emphasised in clinical guidelines. Various publications offer qualitative or semiquantitative scales with gradations corresponding to the different extents of the collaterals, visualised mostly on the basis of CTA images. However, information on their inter-rater reliability is limited. Therefore, the aim of this study is to investigate the inter-rater reliability of the scales for collateral assessment. CTA images of 158 patients in the acute period of IS were used in the study. The assessment of CS was performed by two experts using three methodologies: the modified Tan scale, the Miteff scale, and the Rosenthal scale. Cohen’s kappa, weighted kappa and Krippendorff’s alpha were used as reliability measures. For the modified Tan scale and the Miteff and Rosenthal scales, the weighted kappa values were 0.72, 0.49 and 0.59, respectively. Although the best measure of consistency was found for the modified Tan scale, no statistically significant differences were revealed among the scales. The impact of the CS on the degree of neurological deficit at discharge was shown for the modified Tan and Rosenthal scales. In conclusion, the analysis showed a moderate inter-rater reliability of the three scales, but was not able to distinguish the best one among them. Full article
(This article belongs to the Special Issue Clinical Management of Acute Ischemic Stroke)
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11 pages, 620 KiB  
Article
Higher Leukocyte Count Is Associated with Lower Presence of Carotid Lipid-Rich Necrotic Core: A Sub-Study in the Plaque at RISK (PARISK) Study
J. Clin. Med. 2023, 12(4), 1370; https://doi.org/10.3390/jcm12041370 - 08 Feb 2023
Cited by 1 | Viewed by 1077
Abstract
Background: Increasing evidence suggests that inflammation inside the vessel wall has a prominent role in atherosclerosis. In carotid atherosclerosis in particular, vulnerable plaque characteristics are strongly linked to an increased stroke risk. An association between leukocytes and plaque characteristics has not been investigated [...] Read more.
Background: Increasing evidence suggests that inflammation inside the vessel wall has a prominent role in atherosclerosis. In carotid atherosclerosis in particular, vulnerable plaque characteristics are strongly linked to an increased stroke risk. An association between leukocytes and plaque characteristics has not been investigated before and could help with gaining knowledge on the role of inflammation in plaque vulnerability, which could contribute to a new target for intervention. In this study, we investigated the association of the leukocyte count with carotid vulnerable plaque characteristics. Methods: All patients from the Plaque At RISK (PARISK) study whom had complete data on their leukocyte count and CTA- and MRI-based plaque characteristics were included. Univariable logistic regression was used to detect associations of the leukocyte count with the separate plaque characteristics (intra-plaque haemorrhage (IPH), lipid-rich-necrotic core (LRNC), thin or ruptured fibrous cap (TRFC), plaque ulceration and plaque calcifications). Subsequently, other known risk factors for stroke were included as covariates in a multivariable logistic regression model. Results: 161 patients were eligible for inclusion in this study. Forty-six (28.6%) of these patients were female with a mean age of 70 [IQR 64–74]. An association was found between a higher leukocyte count and lower prevalence of LRNC (OR 0.818 (95% CI 0.687–0.975)) while adjusting for covariates. No associations were found between the leucocyte count and the presence of IPH, TRFC, plaque ulceration or calcifications. Conclusions: The leukocyte count is inversely associated with the presence of LRNC in the atherosclerotic carotid plaque in patients with a recently symptomatic carotid stenosis. The exact role of leukocytes and inflammation in plaque vulnerability deserves further attention. Full article
(This article belongs to the Special Issue Clinical Management of Acute Ischemic Stroke)
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9 pages, 411 KiB  
Article
Endovascular Thrombectomy with or without Intravenous Thrombolysis for Anterior Circulation Large Vessel Occlusion in the Imperial College London Thrombectomy Registry
J. Clin. Med. 2023, 12(3), 1150; https://doi.org/10.3390/jcm12031150 - 01 Feb 2023
Cited by 5 | Viewed by 1445
Abstract
Background and purpose. Mechanical thrombectomy (MT) is the standard of care for eligible patients with a large vessel occlusion (LVO) acute ischemic stroke. Among patients undergoing MT there has been uncertainty regarding the role of intravenous thrombolysis (IVT) and previous trials have yielded [...] Read more.
Background and purpose. Mechanical thrombectomy (MT) is the standard of care for eligible patients with a large vessel occlusion (LVO) acute ischemic stroke. Among patients undergoing MT there has been uncertainty regarding the role of intravenous thrombolysis (IVT) and previous trials have yielded conflicting results regarding clinical outcomes. We aim to investigate clinical, reperfusion outcomes and safety of MT with or without IVT for ischemic stroke due to anterior circulation LVO. Materials and Methods. This observational, prospective, single-centre study included consecutive patients with acute LVO ischemic stroke of the anterior circulation. The primary outcomes were the rate of in-hospital mortality, symptomatic intracranial haemorrhage and functional independence (mRS 0–2 at 90 days). Results. We enrolled a total of 577 consecutive patients: 161 (27.9%) were treated with MT alone while 416 (72.1%) underwent IVT and MT. Patients with MT who were treated with IVT had lower rates of in-hospital mortality (p = 0.037), higher TICI reperfusion grades (p = 0.007), similar rates of symptomatic intracranial haemorrhage (p = 0.317) and a higher percentage of functional independence mRS (0–2) at 90 days (p = 0.022). Bridging IVT with MT compared to MT alone was independently associated with a favorable post-intervention TICI score (>2b) (OR, 1.716; 95% CI, 1.076–2.735, p = 0.023). Conclusions. Our findings suggest that combined treatment with MT and IVT is safe and results in increased reperfusion rates as compared to MT alone. Full article
(This article belongs to the Special Issue Clinical Management of Acute Ischemic Stroke)
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9 pages, 250 KiB  
Article
Post-Stroke Status Epilepticus: Time of Occurrence May Be the Difference?
J. Clin. Med. 2023, 12(3), 769; https://doi.org/10.3390/jcm12030769 - 18 Jan 2023
Viewed by 1258
Abstract
(1) Background: Stroke is one of the most frequent causes of status epilepticus (SE) in adults. Patients with stroke and SE have poorer prognosis than those with stroke alone. We described characteristics and prognosis of early- and late-onset post-stroke SE (PSSE). (2) Methods: [...] Read more.
(1) Background: Stroke is one of the most frequent causes of status epilepticus (SE) in adults. Patients with stroke and SE have poorer prognosis than those with stroke alone. We described characteristics and prognosis of early- and late-onset post-stroke SE (PSSE). (2) Methods: We retrospectively analyzed consecutive stroke patients who experienced a first SE between August 2012 and April 2021, comparing clinical characteristics, stroke, and SE features between early- versus late-onset SE in relation to patients’ outcome. (3) Results: Forty stroke patients experienced PSSE. Fourteen developed an early-onset SE (35%) and twenty-six a late-onset SE (65%). Early-onset SE patients had a slightly higher NIHSS score at admission (6.9 vs. 6.0; p = 0.05). Early-onset SE was more severe than late-onset, according to STESS (Status Epilepticus Severity Score) (3.5 vs. 2.8; p = 0.05) and EMSE (Epidemiology-based Mortality score in Status Epilepticus) score (97.0 vs. 69.5; p = 0.04); furthermore, it had a significant impact on disability at 3-month and 1-year follow-up (p = 0.03 and p = 0.02). SE recurrence and seizures relapse were observed mainly in cases of late-onset SE. (4) Conclusions: Early-onset SE seems to be associated with higher disability in short- and long-term follow-up as possible expression of severe acute brain damage. Full article
(This article belongs to the Special Issue Clinical Management of Acute Ischemic Stroke)
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