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Ischemic Stroke Management: From Symptom Onset to Successful Reperfusion and Beyond

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A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Intensive Care/ Anesthesiology".

Deadline for manuscript submissions: closed (28 February 2023) | Viewed by 16704

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Prof. Dr. Dalius Jatužis

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Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, LT-03101 Vilnius, Lithuania
Interests: cerebrovascular disease; stroke; reperfusion therapy, acute stroke management and prevention; cerebrovascular ultrasound; headache; vertigo
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Special Issue Information

Dear Colleagues,

Stroke is one of the major causes of death and disability worldwide. Despite significant progress over recent decades in treating and reducing the risk of acute ischemic stroke with modern prophylaxis, stroke remains a major challenge for both society and treating physicians. The risk of stroke increases with age, but it is by no means uncommon at a younger age as well. Although diagnostic tests are becoming more accurate and reliable, a number of ischemic strokes remain of unknown origin. Post-stroke phenomena significantly change the lives of patients and their families. Treating stroke and its consequences is a heavy burden on health care systems. Considering all these factors, ischemic stroke has great social and economic implications.

Reperfusion therapy—intravenous thrombolysis and endovascular treatment—is a widely accepted, safe and cost-effective method of treatment of acute ischemic stroke with proven clinical efficacy; however, its broad implementation in daily clinical practice is a difficult issue, especially in economically less developed countries. COVID-19 and the diversion of health system resources to combat this global pandemic add to the challenges of managing acute stroke. Multiple activities in order to promote and implement modern reperfusion therapies for stroke patients are very important, as well as an optimally organized and country-specific stroke prevention, treatment and rehabilitation system. Collecting and monitoring data from stroke treatment sites and countries regarding acute reperfusion therapies, logistics, use of resources and diagnostic investigations, rehabilitation, in-hospital complications, case fatality, and other acute ischemic stroke care performance measures are very important to ensure, compare and monitor the quality of acute stroke management.

Although there have been a number of publications in recent years providing multicentre treatment studies and evidence-based recommendations for stroke management, we still lack reliable data on a range of stroke care questions. How can we organize the system of treatment facilities for acute stroke in a specific country? How can we improve stroke recognition and pre-hospital care for a stroke in a real-world setting? Which specific key-performance indicators are most appropriate for monitoring the quality of acute stroke treatment? Which reperfusion method to choose when the patient is suitable for both of them? What is the optimal treatment for clinical situations that are not defined by widely used guidelines? How do we follow international and national recommendations in our daily practice and is it safe to deviate from them? What are the features of diagnosis and treatment of stroke at a young age? How to safely treat elderly and multimorbid patients? Are the methods of diagnosis, clinical assessment, choice of treatment and outcomes of underrepresented posterior circulation stroke different from the much better studied carotid (anterior circulation) stroke? These are just some of the issues that concern journal readers, stroke doctors, and researchers.

The aim of this Special Issue is to discuss the evidence for the primary and secondary prevention, prehospital, basic and specialized reperfusion therapy of acute ischemic stroke, rehabilitation and management of post-stroke symptoms, with a particular focus on strategies applicable in different countries. The range of topics in the issue is deliberately wide, in order to encourage the coverage of the various topics, perspectives, and controversies surrounding ischemic stroke management. Different types of manuscript submissions, including original preclinical and clinical research articles and up-to-date reviews (narrative and systematic reviews, as well as meta-analyses) are welcomed.

Prof. Dr. Dalius Jatužis
Guest Editor

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Keywords

ischemic stroke
thrombolysis
thrombectomy
reperfusion
acute stroke management
new therapies of stroke
clinical manifestations
stroke recognition
prehospital care
stroke diagnostics
organization of stroke care
stroke in young age
stroke prevention
stroke outcomes
post-stroke symptoms
stroke rehabilitation

Published Papers (8 papers)

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Research

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14 pages, 2285 KiB

Open AccessArticle

Importance of Retesting for the Final Diagnosis of Post-Stroke Cognitive Impairment

by Dominik Koren, Miriam Slavkovska, Marianna Vitkova and Zuzana Gdovinova

Medicina 2023, 59(3), 637; https://doi.org/10.3390/medicina59030637 - 22 Mar 2023

Cited by 2 | Viewed by 1586

Abstract

Background and Objectives: Post-stroke cognitive impairment (PSCI) has been defined as all problems in cognitive function that occur following a stroke. Studies published thus far on the prevalence of PSCI and post-stroke dementia (PSD) have shown conflicting estimates. The aim of this study was screening for cognitive impairment (CogI) in patients with an ischaemic stroke and finding the relationship between CogI (and its changes) and cardiovascular risk factors and imaging procedures—CT/MRI. Materials and Methods: We prospectively included patients with an ischaemic stroke admitted in the period from October 2019 to May 2022. In this period, 1328 patients were admitted, 305 of whom met the established inclusion criteria and underwent an examination of cognitive functions using the Montreal Cognitive Assessment (MoCA). Of these, 50 patients appeared for the control examination after 6 months. Results: In the retested group, CogI at discharge was diagnosed in 37 patients (74%). In follow-up testing after 6 months, CogI was present in 30 patients (60%). Only arterial hypertension (OR: 15; 95% CI; Pearson r: 0.001), lower education level (less than 13 years) (OR: 9.7; 95% CI 2.0–48.5; Pearson r: 0.002), and higher age were significantly associated with CogI after stroke. Conclusions: We established the prevalence of CogI and its course after 6 months in a well-defined group of patients after a mild ischaemic stroke (mean NIHSS: 2 and mean mRS: 1 at the discharge). Our results show that the prevalence of CogI after an ischaemic stroke at discharge is relatively high (74%), and it tends to be a spontaneous reduction. Cognitive functions were changed in 35% of patients. The definition of PSCI was completed in only 24% of individuals. Only an examination several months after a stroke can give us more accurate information about the true prevalence of persistent CogI after a stroke. Full article

(This article belongs to the Special Issue Ischemic Stroke Management: From Symptom Onset to Successful Reperfusion and Beyond)

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6 pages, 272 KiB

Open AccessArticle

Idarucizumab in Dabigatran-Treated Patients with Acute Ischemic Stroke Receiving Thrombolytic Therapy

by Ilga Kikule, Alise Baborikina, Iveta Haritoncenko and Guntis Karelis

Medicina 2022, 58(10), 1355; https://doi.org/10.3390/medicina58101355 - 27 Sep 2022

Cited by 3 | Viewed by 1485

Abstract

Background and Objectives: Thrombolytic therapy with recombinant tissue-type plasminogen activator (rt-PA) is used to treat acute ischemic stroke. Dabigatran is a reversible thrombin inhibitor approved for stroke prevention in patients with nonvalvular atrial fibrillation. In such cases, thrombolytic therapy can be administered to certain patients after idarucizumab treatment. We evaluated the effectiveness of idarucizumab in dabigatran-treated patients receiving rt-PA. Materials and Methods: We included the data of nine idarucizumab-treated patients from the Riga East University Hospital Stroke Registry from 2018 to 2022 in our retrospective medical records analysis. We used the National Institutes of Health Stroke Scale (LV-NIHSS) score and modified Rankin scale (mRS) on admission and discharge to evaluate neurological deficit and functional outcomes. Results: We analyzed the data of nine patients (seven males and two females) with a mean age of 75.67 ± 8.59 years. The median door-to-needle time for all patients, including those who received idarucizumab before rt-PA, was 51 min (IQR = 43–133); the median LV-NIHSS score was 9 (IQR = 6.0–16.0) on admission and 4 (IQR = 2.5–4.0) at discharge; and the intrahospital mortality rate was 11.1% due to intracranial hemorrhage as a complication of rt-PA. Conclusions: Our study shows that idarucizumab as an antidote of dabigatran appears to be effective and safe in patients with acute ischemic stroke. Furthermore, the administration of idarucizumab slightly prolongs the door-to-needle time; however, the majority of cases showed clinical improvement after receiving therapy. Further randomized controlled trials should be performed to evaluate the safety and effectiveness of idarucizumab for acute ischemic stroke treatment. Full article

(This article belongs to the Special Issue Ischemic Stroke Management: From Symptom Onset to Successful Reperfusion and Beyond)

11 pages, 2252 KiB

Open AccessArticle

Impact of Anticoagulants in Reducing Mortality and Disability in Cardioembolic Stroke Patients

by Kristaps Jurjāns, Marija Cērpa, Alise Baborikina, Oskars Kalējs and Evija Miglāne

Medicina 2022, 58(10), 1323; https://doi.org/10.3390/medicina58101323 - 21 Sep 2022

Viewed by 1576

Abstract

Background and Objectives: Stroke is currently the second most common cause of death and disability-adjusted life years worldwide. Previous studies have determined that cardioembolic stroke is associated with higher mortality. Our aim is to compare the long-term outcome and mortality of atherothrombotic, cardioembolic stroke patients and patients taking direct oral anticoagulants (DOACs), and to demonstrate that adequate treatment with DOACs is associated with better results. Materials and Methods: In our retrospective study, we collected the data of ischemic stroke patients who were treated at P. Stradins Clinical University Hospital, Riga, Latvia, Stroke Unit, in the year 2017. In the present study, we analyzed this information to assess the patients’ demographic and clinical data, vascular risk factors, functional and neurological evaluation results, and the use of anticoagulant therapy. Stroke survivors were followed-up via telephone at 30/90/180/365 days and 4 years after being discharged from the hospital. The Latvian version of the National Institutes of Health Stroke Scale (NIHSS-LV) was used to evaluate patients’ neurological outcomes at discharge, and patients’ functional outcomes were evaluated using the modified Rankin scale (mRS). The collected data of the patients were separated into three groups according to the stroke subtype and use of direct oral anticoagulants. Results: A total of 654 ischemic stroke patients were admitted to the hospital in the year 2017. Of all the strokes included in the study, 262 presented an atherothrombotic etiology and 392 presented a cardioembolic etiology. The median age of the patients in the study was 76 years (IQR: 67–83). The median age of patients in the atherothrombotic stroke group was 71 years (IQR = 64–79), in the cardioembolic stroke group it was 79 (IQR = 72–84), and in the DOAC group it was 75 years (IQR = 69–82), respectively. At the period of four years, of all the atherothrombotic stroke survivors 14 (10.5%) had a severe disability, and 64 (48.1%) did not survive. However, 12 (4.1%) of the cardioembolic stroke survivors were severely disabled and 37 (12.5%) had died. In the group of patients taking DOACs 6 (4.5%) had a severe disability and 17 (12.9%) did not survive. In all the patient groups, the leading cause of death was due to severe disability (22%), followed by recurrent cardioembolic events (8%). Conclusions: Previous studies until now have concluded that cardioembolic stroke is associated with higher mortality and an unfavorable functional outcome. In our study, the cardioembolic stroke group and the DOAC group had a statistically significant higher percentage of patients with congestive heart failure and older age, but their long-term mortality was lower and they achieved independence more often than the atherothrombotic stroke patients. The proper use of anticoagulants shows great improvement in long-term survival rate and functional outcome. Full article

(This article belongs to the Special Issue Ischemic Stroke Management: From Symptom Onset to Successful Reperfusion and Beyond)

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7 pages, 566 KiB

Open AccessArticle

Association of Vertebral Artery Hypoplasia and Vertebrobasilar Cerebrovascular Accident

by Augenijus Vilimas, Virginija Gaigalaitė, Mykolas Urbonas and Dalius Jatužis

Medicina 2022, 58(9), 1189; https://doi.org/10.3390/medicina58091189 - 31 Aug 2022

Cited by 1 | Viewed by 1692

Abstract

Background and Objectives: Vertebral artery hypoplasia (VAH) is a controversial risk factor for cerebral infarction. The aim of this study was to analyze the prevalence of vertebral artery hypoplasia and to evaluate its association with vertebrobasilar cerebrovascular accidents. Materials and Methods: The study was conducted in the Neurology Departments of the Republican Vilnius University Hospital from 2015 to 2020. Data of 742 subjects (133 patients with posterior circulation infarction or vertebral artery syndrome (PCI/VAS), 80 patients with anterior circulation infarction (ACI) and 529 control subjects with no symptoms of cerebrovascular accident) were analyzed. Ultrasound examination of the extracranial internal carotid and vertebral arteries (VA) was performed, risk factors were recorded. Results: The mean age of the subjects was 64.51 ± 13.02 years. In subjects with PCI/VAS the diameter of VA was smaller, and the prevalence of VAH was higher compared to those in subjects with ACI and in the control group. A higher degree of VAH in subjects younger than 65 years of age increased the risk of PCI/VAS. Subjects with non-dominant VA diameter of 2.7–2.9 mm had 2.21 times higher risk of PCI/VAS, subjects with non-dominant VA diameter of 2.5–2.6 mm had 2.36 times higher risk of PCI/VAS, and subjects with non-dominant VA diameter of 2.2–2.4 mm had 4.12 times higher risk of PCI/VAS compared with subjects with non-dominant VA diameter of ≥3 mm. Among patients with PCI/VAS those with VAH had lower rates of ischemic heart disease compared with patients with normal VA diameter. There was no difference in the rates of other risk factors between PCI/VAS patients with and without VAH. Conclusions: Vertebral artery hypoplasia is not a rare finding in individuals without symptoms of cerebrovascular accident, but more frequent in patients with vertebrobasilar cerebral infarction or vertebrobasilar artery syndrome. Vertebral artery hypoplasia can be considered a risk factor for posterior circulation infarction in subjects under 65 years of age. Full article

(This article belongs to the Special Issue Ischemic Stroke Management: From Symptom Onset to Successful Reperfusion and Beyond)

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10 pages, 1298 KiB

Open AccessArticle

Implementation of the Helsinki Model at West Tallinn Central Hospital

by Katrin Gross-Paju, Ulvi Thomson, Raul Adlas, Helle Jaakmees, Karin Kannel, Sandra Marii Mallene, Svetlana Mironenko, Agnes Reitsnik, Ain Vares and Sandra Ütt

Medicina 2022, 58(9), 1173; https://doi.org/10.3390/medicina58091173 - 29 Aug 2022

Cited by 3 | Viewed by 1533

Abstract

Ischemic stroke is defined as neurological deficit caused by brain infarction. The intravenous tissue plasminogen activator, alteplase, is an effective treatment. However, efficacy of this method is time dependent. An important step in improving outcome and increasing the number of patients receiving alteplase is the shortening of waiting times at the hospital, the so-called door-to-needle time (DNT). The comprehensive Helsinki model was proposed in 2012, which enabled the shortening of the DNT to less than 20 min. Background and Objectives: The aim of this study was to analyze the transferability of the suggested model to the West Tallinn Central Hospital (WTCH). Materials and Methods: Since the first thrombolysis in 2005, all patients are registered in the WTCH thrombolysis registry. Several steps following the Helsinki model have been implemented over the years. Results: The results demonstrate that the number and also the percent of thrombolysed stroke patients increased during the years, from a few thrombolysis annually, to 260 in 2021. The mean DNT dropped significantly to 33 min after the implementation of several steps, from the emergency medical services (EMS) prenotification with a phone call to the neurologists, to the setting-up of a thrombolysis team based in the stroke unit. Also, the immediate start of treatment using a computed tomography table was introduced. Conclusions: In conclusion, several implemented steps enabled the shortening of the DNT from 30 to 25.2 min. Short DNTs were achieved and maintained only with EMS prenotification. Full article

(This article belongs to the Special Issue Ischemic Stroke Management: From Symptom Onset to Successful Reperfusion and Beyond)

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13 pages, 664 KiB

Open AccessArticle

Pre-Hospital Delay in Acute Ischemic Stroke Care: Current Findings and Future Perspectives in a Tertiary Stroke Center from Romania—A Cross-Sectional Study

by Elena Oana Terecoasă, Răzvan Alexandru Radu, Anca Negrilă, Iulian Enache, Bogdan Cășaru and Cristina Tiu

Medicina 2022, 58(8), 1003; https://doi.org/10.3390/medicina58081003 - 27 Jul 2022

Cited by 11 | Viewed by 2236

Abstract

Background and objectives: The time interval between stroke onset and hospital arrival is a major barrier for reperfusion therapies in acute ischemic stroke and usually accounts for most of the onset-to-treatment delay. The present study aimed to analyze the pre-hospital delays for patients with acute ischemic stroke admitted to a tertiary stroke center in Romania and to identify the factors associated with a late hospital arrival. Material and methods: The study population consisted of 770 patients hospitalized with the diagnosis of acute ischemic stroke in the University Emergency Hospital Bucharest during a 6-month period, between 1 January and 30 June 2018. Data regarding pre-hospital delays were prospectively collected and analyzed together with the demographic and clinical characteristics of the patients. Results: In total, 31.6% of patients arrived at the hospital within 4.5 h from stroke onset and 4.4% in time intervals between 4.5 and 6 h from the onset, and 28.7% of the patients reached the hospital more than 24 h after onset of symptoms. Transport to hospital by own means was the only factor positively associated with arrival to hospital > 4.5 h from stroke onset and more than doubled the odds of late arrival. Factors negatively associated with hospital arrival > 4.5 h after stroke onset were prior diagnosis of atrial fibrillation, initial National Institute of Health Stroke Scale (NIHSS) score ≥ 16 points, presence of hemianopsia, facial palsy and sensory disturbance. Factors increasing the odds of hospital arrival after 24 h from stroke onset were living alone and living in rural areas. Conclusions: Almost one in three ischemic stroke patients presenting to our center reaches hospital more than 24 h after onset of symptoms. These findings highlight the need for urgent measures to improve not only stroke awareness but also pre-hospital protocols in order to provide timely and appropriate care for our stroke patients. Full article

(This article belongs to the Special Issue Ischemic Stroke Management: From Symptom Onset to Successful Reperfusion and Beyond)

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Review

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9 pages, 309 KiB

Open AccessReview

Stroke Scales as Assessment Tools in Emergency Settings: A Narrative Review

by Hrvoje Budinčević, Andrija Meštrović and Vida Demarin

Medicina 2022, 58(11), 1541; https://doi.org/10.3390/medicina58111541 - 27 Oct 2022

Cited by 3 | Viewed by 4527

Abstract

In the last 20 years, substantial improvements have been made in stroke recanalization treatment. Good outcomes after modern reperfusion treatment require the rapid and accurate identification of stroke patients. Several stroke rating scales are available or have been proposed for the early recognition of stroke and the evaluation of stroke severity and outcome. This review aims to provide an overview of commonly used stroke scales in emergency and clinical settings. The most commonly used scale in a prehospital setting for stroke recognition is the Face, Arms, Speech, Time (FAST) test. Among many prehospital stroke scales, the Los Angeles Prehospital Stroke Screen has the highest sensitivity and specificity for confirming stroke diagnosis. The National Institutes of Health Stroke Scale (NIHSS) is the most recommended tool for the evaluation of stroke patients in hospital settings and research, and it has two variants: the shortened NIHSS for Emergency Medical Service and the modified NIHSS. The evaluation of comatose patients usually involves assessment with the Glasgow Coma Scale, which is very useful in patients with hemorrhagic stroke or traumatic brain injury. In patients with subarachnoid hemorrhage, the outcome is usually accessed with the Hunt and Hess scale. A commonly used tool for stroke outcome evaluation in clinical/hospital settings and research is the modified Rankin scale. The tools for disability evaluation are the Barthel Index and Functional Independence Measure. Full article

(This article belongs to the Special Issue Ischemic Stroke Management: From Symptom Onset to Successful Reperfusion and Beyond)

Other

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7 pages, 1037 KiB

Open AccessCase Report

The Impact of Revascularization in a Patient with Atypical Manifestations of Hypoperfusion

by Sintija Strautmane, Zanda Priede and Andrejs Millers

Medicina 2022, 58(10), 1328; https://doi.org/10.3390/medicina58101328 - 22 Sep 2022

Viewed by 1366

Abstract

Background and Objectives: Carotid revascularization is one of the most effective treatment options in patients with severe carotid artery stenosis causing hypoperfusion in basal ganglia. Atypical manifestations include hyperkinetic movements, noted as extremely rare. We report a case about a patient with 2-months-long complaints of Uncontrollable movements in his right side of the body subsided after carotid revascularization. Case presentation: A 71-year-old male was admitted to Pauls Stradins Clinical University Hospital with the main complaints of 2-months-long uncontrollable movements in his right hand and his right leg. When performing coordination tasks, slight inaccuracy was noted with the right-side extremities. Hyperkinetic movements—choreoathetosis in the right side of the patient’s face, arm, and leg—were seen. Computed tomography angiography revealed subocclusion in the proximal segment of the left internal carotid artery and 30% stenosis in the proximal segment of the right internal carotid artery. The patient was consulted by a vascular surgeon. Eversion endarterectomy of the left internal carotid artery was performed. The early postoperative period occurred without complications. The patient was discharged from the hospital 2 days after the surgery in good overall health condition. Two months later, choreoathetotic movements in his right side of the body had markedly decreased. No focal neurologic deficits were noted. Conclusions: Revascularization may be effective by eliminating emboli and stenosis, leading to hypoperfusion in watershed territories. A case of a 71-year-old male patient with the main complaints of 2-months-long uncontrollable movements in his right side of the body subsiding after carotid revascularization was demonstrated. It is vital to recognize atypical manifestations of hypoperfusion, associated with stenosis in internal carotid arteries, to early make a diagnosis, to perform an appropriate treatment, and to reduce the risk of cerebral infarction in the future, resulting in a longer high-quality life for the patient. Full article

(This article belongs to the Special Issue Ischemic Stroke Management: From Symptom Onset to Successful Reperfusion and Beyond)

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