Search Results (11)

Objective: To evaluate the safety and efficacy of recombinant human prourokinase (rhPro-UK) administered via intravenous (IV) and intra-arterial (IA) routes in acute ischemic stroke (AIS) patients compared with standard treatments. Methods: A comprehensive search was conducted in accordance with PRISMA guidelines across Scopus, Web of Science, and PubMed until 11 December 2024. Randomized controlled trials (RCTs) assessing rhPro-UK’s efficacy and safety were included. Outcomes included the modified Rankin Scale (mRS), the National Institutes of Health Stroke Scale (NIHSS), mortality, and adverse events (AEs). Data analysis used risk difference (RD) with 95% confidence intervals (CIs). Results: Six RCTs (n = 3993) met the inclusion criteria. IV rhPro-UK showed comparable efficacy to the comparator for the mRS 0–1 at 90 days (RD: 0.00, 95% CI: [−0.04, 0.04]) and the mRS 0–2 (RD: −0.01, 95% CI: [−0.03, 0.01], P = 0.23). IA rhPro-UK significantly improved the mRS 0–1 (RD: 0.13, 95% CI: [0.01, 0.26], P = 0.04). The NIHSS reduction was significant for IV rhPro-UK (MD: −0.83, 95% [CI: −1.36, −0.29]). IV rhPro-UK did not significantly reduce the risk of systemic bleeding (RD: −0.10, 95% CI: [−0.24, 0.03], P = 0.12), serious AEs (RD: −0.01, 95% CI: [−0.04, 0.02], P = 0.53), or mortality (RD: 0.01, 95% CI: −0.01, 0.02). IA rhPro-UK significantly increased hemorrhage with neurological deterioration (RD: 0.08, 95% CI: [0.01, 0.14], P = 0.02). Conclusions: IV rhPro-UK provides non-inferior efficacy to both alteplase and standard care with a better safety profile at 35 mg, while IA rhPro-UK enhances functional outcomes in middle cerebral artery occlusions, albeit with safety concerns. Further trials are needed to confirm long-term outcomes, optimal dosing, and broader applicability. Full article

Background: In patients with acute ischemic stroke, the standard of care is to perform intra-arterial endovascular thrombectomy in addition to intravenous thrombolysis. In this study, we investigated the different anesthetic techniques chosen for this procedure and clinical outcomes. Methods: Patients undergoing endovascular procedures were divided into three groups. The first group consisted of patients who received general anesthesia, the second group underwent the procedure under conscious sedation and local anesthesia at the catheter insertion site, and lastly the third group included patients who received only local anesthesia at the catheter insertion site, without sedation. Results: During the endovascular procedure, we did not notice significant differences in vital parameters, in particular the mean blood pressure (MAP) between patients treated with different types of anesthesia. Also, the duration of the revascularization did not show significant differences between the three groups. The main point is the absence of differences in terms of functional and clinical outcomes, using various scores as reference, such as the National Institutes of Health Stroke Scale (NIHSS) score at 7 days, NIHSS and Modified Rankin Scale (MRS) at time of discharge, and MRS after 3 months. These scores did not show significant differences in groups treated with different types of anesthesia. Conclusions: The rate of success of the revascularization procedure is almost overlapping between patients treated with conscious sedation and general anesthesia. In addition, we did not notice significant differences between groups in terms of functional and clinical outcomes. Considering the possible usefulness of applying conscious sedation, at OCSAE of Baggiovara, an internal protocol for conscious sedation was introduced to standardize the treatment in patients undergoing endovascular procedures. Full article

Stroke management employs a variety of diagnostic imaging modalities, image processing and analysis methods, and treatment procedures. This work categorizes methods for stroke imaging, image processing and analysis, and treatment, and provides their taxonomies illustrated by a state-of-the-art review. Imaging plays a critical role in stroke management, and the most frequently employed modalities are computed tomography (CT) and magnetic resonance (MR). CT includes unenhanced non-contrast CT as the first-line diagnosis, CT angiography, and CT perfusion. MR is the most complete method to examine stroke patients. MR angiography is useful to evaluate the severity of artery stenosis, vascular occlusion, and collateral flow. Diffusion-weighted imaging is the gold standard for evaluating ischemia. MR perfusion-weighted imaging assesses the penumbra. The stroke image processing methods are divided into non-atlas/template-based and atlas/template-based. The non-atlas/template-based methods are subdivided into intensity and contrast transformations, local segmentation-related, anatomy-guided, global density-guided, and artificial intelligence/deep learning-based. The atlas/template-based methods are subdivided into intensity templates and atlases with three atlas types: anatomy atlases, vascular atlases, and lesion-derived atlases. The treatment procedures for arterial and venous strokes include intravenous and intraarterial thrombolysis and mechanical thrombectomy. This work captures the state-of-the-art in stroke management summarized in the form of comprehensive and straightforward taxonomy diagrams. All three introduced taxonomies in diagnostic imaging, image processing and analysis, and treatment are widely illustrated and compared against other state-of-the-art classifications. Full article

This retrospective study aimed to evaluate the outcomes of 13 patients with acute superior mesenteric artery (SMA) occlusion who underwent intra-arterial urokinase thrombolysis between 2008 and 2020. On angiography, seven presented with complete SMA occlusion versus six with incomplete occlusion. The median time from abdominal pain to attempting urokinase thrombolysis was 15.0 h (interquartile range, 6.0 h). After urokinase therapy, bowel perfusion was restored with bowel preservation in six patients; however, treatment failed in the other seven patients. The degree of SMA occlusion (complete vs. incomplete, p = 0.002), degree of recanalisation (p = 0.012), and length of stay (p = 0.032) differed significantly between groups. Of the seven patients with complete SMA occlusion, six underwent bowel resection, of whom three died, and the remaining patient died of shock due to delayed surgery. Among the six patients with incomplete SMA occlusion, no bowel resection was performed. In our experience, intra-arterial urokinase thrombolysis may serve as an adjunctive treatment modality, being a potential replacement for open thrombectomy that is able to preserve the bowel and obviate surgery in cases of incomplete SMA occlusion; however, its use is unsuitable in cases of complete SMA occlusion, for which surgery is warranted. Full article

Purpose: To report our thrombolytic technique, treatment strategy, and clinical outcomes for porto-mesenteric venous thrombosis (PMVT) in non-cirrhotic patients. Methods: Sixteen acute or chronic non-cirrhotic PMVT patients (mean age: 48.6 years) with imminent intestinal ischemia were enrolled from 2004 to 2020. Eight patients presented thrombus extension into the peripheral mesenteric vein, close to the venous arcade. Transhepatic catheter-directed thrombolysis (CDT) was performed by urokinase infusion (60,000–30,000 IU/h concomitant with heparin 300–400 IU/h), catheter aspiration, and/or balloon dilation/stent placement. Additional intra-arterial mesenteric infusion of urokinase (30,000 IU/h) was given in patients with the peripheral mesenteric venules involved. Transjugular intrahepatic porto-systemic shunt (TIPS) was created in patients with poor recanalization of the intrahepatic portal flow (PV). Results: The transhepatic route was adopted in all patients, with adjunct indirect mesenteric arterial thrombolytic infusion in eight patients. A total of up to 20.4 million IU urokinase was infused for 1–21 days’ treatment duration. TIPS was created in three patients with recanalization failure of the intrahepatic PV. Technical success was achieved in 100% of patients with complete recanalization of 80% and partial recanalization of 20%. No major procedure-related complications were encountered. The 30-day mortality rate was 6.7%. The overall two-year primary patency was 84.6%. Conclusions: CDT can be performed as a primary salvage treatment once the diagnosis is made. CDT via the transhepatic route with tailored thrombolytic regimen is safe and effective for both acute and chronic PMVT. TIPS creation can be preserved in non-cirrhotic PMVT patients if intrahepatic PV recanalization fails. Full article

Interventional neuroradiology is characterized by engineering- and experience-driven device development with design improvements every few months. However, clinical validation of these new devices requires lengthy and expensive randomized controlled trials. This contribution proposes a machine learning-based in silico study design to evaluate new devices more quickly with a small sample size. Acute diffusion- and perfusion-weighted MRI, segmented one-week follow-up imaging, and clinical variables were available for 90 acute ischemic stroke patients. Three treatment option-specific random forest models were trained to predict the one-week follow-up lesion segmentation for (1) patients successfully recanalized using intra-arterial mechanical thrombectomy, (2) patients successfully recanalized using intravenous thrombolysis, and (3) non-recanalizing patients as an analogue for conservative treatment for each patient in the sample, independent of the true group membership. A repeated-measures analysis of the three predicted follow-up lesions for each patient revealed significantly larger lesions for the non-recanalizing group compared to the successful intravenous thrombolysis treatment group, which in turn showed significantly larger lesions compared to the successful mechanical thrombectomy treatment group (p < 0.001). A groupwise comparison of the true follow-up lesions for the three treatment options showed the same trend but did not reach statistical significance (p = 0.19). We conclude that the proposed machine learning-based in silico trial design leads to clinically feasible results and can support new efficacy studies by providing additional power and potential early intermediate results. Full article

Objective: To identify factors associated with early angiographic reperfusion improvement (EARI) following intra-arterial fibrinolytics (IAF) after failed or incomplete mechanical thrombectomy (MT). Methods: A subset of patients treated with MT and IAF rescue after incomplete reperfusion included in the INFINITY (INtra-arterial FIbriNolytics In ThrombectomY) multicenter observational registry was analyzed. Multivariable logistic regression was used to identify factors associated with EARI. Heterogeneity of the clinical effect of EARI on functional independence (defined as modified Rankin Score ≤2) was tested with interaction terms. Results: A total of 228 patients (median age: 72 years, 44.1% female) received IAF as rescue for failed or incomplete MT and had a post-fibrinolytic angiographic control run available (50.9% EARI). A cardioembolic stroke origin (adjusted odds ratio (aOR) 3.72, 95% confidence interval (CI) 1.39–10.0) and shorter groin puncture to IAF intervals (aOR 0.82, 95% CI 0.71–0.95 per 15-min delay) were associated with EARI, while pre-interventional thrombolysis showed no association (aOR 1.15, 95% CI 0.59–2.26). The clinical benefit of EARI after IAF seemed more pronounced in patients without or only minor early ischemic changes (Alberta Stroke Program Early Computed Tomography Score (ASPECTS) ≥9, aOR 4.00, 95% CI 1.37–11.61) and was absent in patients with moderate to severe ischemic changes (ASPECTS ≤8, aOR 0.94, 95% CI 0.27–3.27, p for interaction: 0.095). Conclusion: Early rescue and a cardioembolic stroke origin were associated with more frequent EARI after IAF. The clinical effect of EARI seemed reduced in patients with already established infarcts. If confirmed, these findings can help to inform patient selection and inclusion criteria for randomized-controlled trials evaluating IAF as rescue after MT. Full article

In the last decades, there has been great progress in the field of stroke. With the introduction of acute therapies (intravenous thrombolysis and intra-arterial treatment), the outcome after stroke has improved significantly. Better prevention, improved acute therapy, and acute rehabilitation improved the morbidity and mortality rate after stroke. Gender differences in risk factors and epidemiology have been known for a long time, but lately attention to gender differences in stroke has increased. The aim of this mini-review is to demonstrate gender disparities in stroke with a focus on epidemiology, specific risk factors (gender-specific and unspecific), and outcomes. The influence of some risk factors for stroke is stronger in women (atrial fibrillation and hypertension) and there are risk factors exclusive to women such as pregnancy, pregnancy-associated hypertensive disorders, oral contraceptives, and hormonal replacement treatment. Data on the impact of other risk factors are inconsistent. The worse outcome after a stroke is mainly caused by demographic characteristics in women. Specific gender research is needed to better understand gender disparities in stroke to improve prevention strategies and treatment for women. Full article

Although thrombectomy is beneficial for most stroke patients with large vessel occlusion (LVO), it has added new issues in acute management due to intensive care support. In this prospective cohort study, we described the patients admitted to our neuro-intensive care unit (NICU) after thrombectomy in order to assess factors linked to functional outcomes. The outcome was independency assessed for stroke patients consecutively admitted to NICU for an ischemic stroke due to LVO of the anterior cerebral circulation that underwent intra-arterial mechanical thrombectomy (IAMT), either in combination with intravenous thrombolysis (IVT) in eligible patients or alone in patients with contraindications for IVT. Overall, 158 patients were enrolled. IVT (odds ratio (OR), 3.78; 95% confidence interval (CI), 1.20–11.90; p = 0.023) and early naso-gastric tube removal (OR, 3.32; 95% CI, 1.04–10.59 p = 0.042) were associated with good outcomes, whereas a high baseline National Institutes of Health Stroke Scale (NIHSS) score (OR, 0.72 for each point of increase; 95% CI, 0.61–0.85; p < 0.001) was a predictor of poor outcomes at 3 months. Older age (OR, 0.95 for each year of increase; 95% CI, 0.92–0.99; p = 0.020) and hemorrhagic transformation (OR, 0.31; 95% CI, 0.11–0.84; p = 0.022) were predictors of poor outcomes after IAMT, whereas a modified Treatment in Cerebral Infarction (mTICI) score of 2b/3 was a predictor of good outcomes (OR, 7.86; 95% CI, 1.65–37.39; p = 0.010) at 6 months. Our results show that acute stroke patients with LVO who require NICU management soon after IAMT may show specific clinical factors influencing short- and long-term neurologic independency. Full article

Stroke has become an absolute emergency that is treated by additional endovascular means or by replacing pharmacological options. Modern neuroradiological techniques such as computed tomography (CT) allow us to examine multiple parameters of the diseased brain. These focused on the parenchyma and hemodynamics for pretherapeutic decisions. However, it has become evident that the clot is the current target for interventional measures. Clot length is established as a marker for recanalization. The dense artery sign is known as an acute CT sign of stroke that is readily visible on acute nonenhanced CT. The rationale behind our study was to study if clot density might represent clot vulnerability or resistance to treatment. We conducted a prospective study of all consecutive stroke patients admitted to our hospital over 1 year, who presented with signs of acute middle cerebral artery stroke within the therapeutic window, and who underwent either intravenous or combined intravenous and intra-arterial thrombolysis. All patients were evaluated with a complete stroke CT protocol, transcranial color-coded duplex sonography monitoring, and clinical evaluation with the National Institutes of Health Stroke Scale (NIHSS) score. We measured clot length using planimetry on unenhanced CT and measured Hounsfield units in the clots on the same images. A total of 31 patients were included in the study (19 men, 12 women, aged 35–90 years). We found that patients with a longer clot on the unenhanced CT had a higher NIHSS score, confirming previous literature. However, we found that patients with a lower clot density recanalized to a more marked degree and had a better clinical outcome. Patients who did not recanalize had a higher clot density (49 Hounsfield units) than those who did recanalize (23 Hounsfield units). Overall, measuring the clot seems to be an important additional parameter to be taken into account. In our study, CT clot density seems to correlate with clinical outcome and recanalization. The higher density seems to represent a higher red blood cell content. This is evidence that clot composition could play a much more important role in acute stroke than thought until now and characterizing it with imaging may help in choosing the adequate treatment modality. Higher density seems to reflect erythrocyte content. Therefore, patients with a longer and denser clot may necessitate direct thrombectomy. Full article

Basilar artery occlusion may be associated with a poor prognosis in the absence of recanalization. Choices in aggressive treatment for this potentially fatal condition vary from intra-arterial or intravenous thrombolysis, endovascular removal, or a combination of the two, with adjunct anti-coagulation therapy. These therapies have proven to be effective in recanalization, whereas conservative management with anti-coagulants alone has had more limited success in the literature. We report a case of basilar artery occlusion managed conservatively with unfractionated heparin, resulting in complete recanalization 3.5 months after symptom onset. Conservative management of basilar artery occlusion with unfractionated heparin was associated with complete recanalization long after symptom onset. Full article