Yearly Archives: 2021

Vignan Yogendrakumar, MD, MSc
@VYogendrakumar

Tan Z, Parsons M, Bivard A, Sharma G, Mitchell P, Dowling R, Bush S, Xu A, Yan B. Optimal Tissue Reperfusion Estimation by Computed Tomography Perfusion Post-Thrombectomy in Acute Ischemic Stroke. Stroke. 2021.

In the thrombectomy era of acute stroke care, it is commonplace to utilize mTICI scores as one of the primary measures of assessing reperfusion status immediately post-procedure. In many studies, it is common to see a measure of mTICI scores 2b-3 as a representation of a good study outcome. However, registry data shows us that mTICI 2b scores are associated with an independent functional state in only 40% of patients. While the surrogate use of mTICI status to represent tissue reperfusion status is certainly a reasonable approach, the association between mTICI score and actual tissue status remains unclear.

In this study by Tan and colleagues, acute stroke patients treated at the Royal Melbourne Hospital with endovascular clot retrieval underwent CT or MRI perfusion at 24-36 hours post procedure. Comparing the baseline and follow-up perfusion scans, the authors defined optimal tissue reperfusion (TOR) as a >90% reduction of penumbra (using TMax>6s) volume. In 82 patients, those who had higher mTICI scores were more likely to achieve TOR at follow-up. Notably, achieving mTICI scores of 2c or 3 were more likely to be associated with TOR compared to mTICI 2b. Clinically, TOR was associated with improved clinical outcomes in multivariable logistic regression models.

Farah Aleisa, MD

Burgos AM, Saver JL. Evidence that Tenecteplase Is Noninferior to Alteplase for Acute Ischemic Stroke: Meta-Analysis of 5 Randomized Trials. Stroke. 2019;50:2156–2162.

Tenecteplase (TNK) is a tissue-type plasminogen activator modified by 3 amino acids from alteplase, and it has the potential to reperfuse brain tissue in case of blocked brain vessels. It has greater fibrin specificity resulting in lower bleeding risks,¹ and it has initial serum half-life of 20 minutes and a mean terminal half-life of 100 minutes, such that it can be given as a bolus dose on a weight-adjusted basis,² being given even in the pre-hospital setting, which allows faster time to reperfusion and less delay for endovascular therapy if needed.

There are 5 independent randomized trials that have studied the efficacy of TNK in comparison to altelplase (ALT) in acute ischemic stroke.^3-7 These trials enrolled a total of 1585 patients (828 TNK, 757 ALT), mean National Institutes of Health Stroke Scale (NIHSS) at baseline was 7, and mean time from last known well to treatment start was 148 minutes. All patients with ALT received standard 0.9 mg/kg dosing; TNK dosing was one-time bolus only, at doses of 0.1 mg/kg in 6.8% of patients, 0.25 mg/kg in 24.6%, and 0.4 mg/kg in 68.6%.

Hannah Roeder, MD, MPH

Desai SM, Malhotra K, Ramaiah G, Tonetti DA, Haq W, Jovin TG, Jadhav AP. Rescue of Neglect and Language Impairment After Stroke Thrombectomy. Stroke. 2021.

The presence of cortical signs, such as aphasia and neglect, on a stroke code examination prompts neurologists to investigate for the presence of a large vessel occlusion (LVO) and to determine if the patient may benefit from thrombectomy. Can the rescue or persistence of cortical signs following mechanical thrombectomy (MT) help us predict outcomes among stroke patients?

The authors performed a retrospective analysis of the stroke database at a single Comprehensive Stroke Center to assess the impact of neglect and aphasia on clinical outcomes for patients with right and left anterior LVO, respectively. They found that a significant majority of patients with right-sided LVOs presented with neglect (71%) and patients with left-sided LVOs presented with language impairment (93%). MT resulted in “rescue of neglect” (31%) and “rescue of language impairment” (23%) in a minority of cases but was an independent and better predictor of functional independence (mRS 0-2) and survival even after adjustment for NIHSS and infarct volume.