Pre-thrombolysis serum sodium concentration is associated with post-thrombolysis symptomatic intracranial hemorrhage in ischemic stroke patients

 Useless with no information on maintaining serum sodium concentrations to the right level!

Pre-thrombolysis serum sodium concentration is associated with post-thrombolysis symptomatic intracranial hemorrhage in ischemic stroke patients

Xiaolan WuZhuangzhuang Jiang^*Dongjuan XuRufang ZhangHongfei Li

• Department of Neurology, Dongyang People’s Hospital, Affiliated to Wenzhou Medical University, Dongyang, China

Background and aim: Symptomatic intracranial hemorrhage (sICH) was the most serious complication associated with alteplase intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) patients. However, the relationship between serum sodium levels and post-thrombolysis symptomatic intracranial hemorrhage has not been investigated. Therefore, the aim of this study was to investigate the relationship between pre-thrombolysis serum sodium levels and sICH after IVT, as well as to explore the optimal pre-thrombolysis serum sodium levels for lowering the risk of sICH following IVT.

Methods: From July 1, 2017 to April 30, 2023, out-of-hospital AIS patients who received IVT in the emergency department were enrolled in this study. Serum sodium levels were measured at admission prior to IVT, and National Institutes of Health Stroke Scale scores were continuously assessed during and after thrombolysis. Routine follow-up neuroimaging was performed between 22 to 36 h after IVT. Initially, three logistic regression models and restricted cubic splines (RCS) were established to investigate the relationship between serum sodium levels and post-thrombolysis sICH. Furthermore, to evaluate the predictive value of serum sodium for post-thrombolysis sICH, we compared area under the receiver operating characteristic curve (AUROC) and net reclassification improvement (NRI) before and after incorporating serum sodium into traditional models. Finally, subgroup analysis was conducted to explore interactions between serum sodium levels and other variables.

Results: A total of 784 AIS patients who underwent IVT were enrolled, among whom 47 (6.0%) experienced sICH. The median serum sodium concentration for all patients was 139.10 [interquartile ranges (IQR): 137.40–141.00] mmol/L. Patients who developed sICH had lower serum sodium levels than those without sICH [138.20(IQR:136.00–140.20) vs. 139.20(IQR:137.40–141.00), p = 0.031]. Logistic regression analysis (model 3) revealed a 14% reduction in the risk of post-thrombolysis sICH for every 1 mmol/L increase in serum sodium levels after adjusting for confounding variables (p < 0.001). The risk of post-thrombolysis sICH was minimized within the serum sodium range of 139.1–140.9 mmol/L compared to serum sodium concentration below 137.0 mmol/L [odds ratio (OR) = 0.33, 95% confidence interval (CI): 0.13–0.81] in model3. Furthermore, there was a significant trend of decreasing risk for sICH as serum sodium concentrations increased across the four quartiles (P for trend = 0.036). The RCS analysis indicated a statistically significant reduction in the risk of sICH as serum sodium levels increased when the concentration was below 139.1 mmol/L. Incorporating serum sodium into traditional models improved their predictive performance, resulting in higher AUROC and NRI values. Subgroup analysis suggested that early infarct signs (EIS) appeared to moderate the relationship between serum sodium and sICH (p < 0.05).

Conclusion: Lower serum sodium levels were identified as independent risk factors for post-thrombolysis sICH. Maintaining pre-thrombolysis serum sodium concentrations above 139.1 mmol/L may help reduce the risk of post-thrombolysis sICH.

Contemporary Prestroke Dual Antiplatelet Use and Symptomatic Intracerebral Hemorrhage Risk After Thrombolysis

 No clue. Ask your doctor.

Contemporary Prestroke Dual Antiplatelet Use and Symptomatic Intracerebral Hemorrhage Risk After Thrombolysis

Teng J. Peng, MD¹; Lee H. Schwamm, MD²; Gregg C. Fonarow, MD³; et al Ameer E. Hassan, DO⁴; Michelle Hill, MS, RN, AGCNS-BC, CNRN, SCRN⁵; Steven R. Messé, MD⁶; Fatima Coronado, MD, MPH⁷; Guido J. Falcone, MD, ScD²; Richa Sharma, MD, MPH²

Author Affiliations

JAMA Neurol. Published online May 20, 2024. doi:10.1001/jamaneurol.2024.1312

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• Editorial
  Symptomatic Hemorrhage Risks in Stroke Thrombolysis
  Shyam Prabhakaran, MD, MS; Jose G. Romano, MD
  JAMA Neurology

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Key Points

Question  Is prestroke antiplatelet therapy associated with an increased risk of symptomatic intracerebral hemorrhage (sICH) after treatment with intravenous alteplase?

Findings  In this cohort study of 321 819 patients from the Get With The Guidelines–Stroke registry, prestroke single and dual antiplatelet exposure was associated with an increased risk of sICH. There were no differences in rates of sICH or functional outcomes in aspirin-clopidogrel vs aspirin-ticagrelor groups.

Meaning  Prestroke dual antiplatelet therapy was associated with a significantly elevated risk of sICH, but the absolute increase in risk was small.

Abstract

Importance  Intravenous alteplase (IV-tPA) can be administered to patients with acute ischemic stroke but is associated with symptomatic intracerebral hemorrhage (sICH). It is unclear if patients taking prestroke dual antiplatelet therapy (DAPT) are at higher risk of sICH.

Objective  To determine the associated risk of sICH in patients taking prestroke dual antiplatelet therapy receiving alteplase for acute ischemic stroke using propensity score matching analysis.

Design, Setting, and Participants  This cohort study used data from the American Heart Association and American Stroke Association Get With The Guidelines–Stroke (GWTG-Stroke) registry between 2013 and 2021. Data were obtained from hospitals in the GWTG-Stroke registry. This study included patients hospitalized with acute ischemic stroke and treated with IV-tPA. Data were analyzed from January 2013 to December 2021.

Exposures  Prestroke DAPT before treatment with IV-tPA for acute ischemic stroke.

Main Outcome Measures  sICH, In-hospital death, discharge modified Rankin scale score, and other life-threatening systemic hemorrhages.

Results  Of 409 673 participants, 321 819 patients (mean [SD] age, 68.6 [15.1] years; 164 587 female [51.1%]) who were hospitalized with acute ischemic stroke and treated with IV-tPA were included in the analysis. The rate of sICH was 2.9% (5200 of 182 344), 3.8% (4457 of 117 670), and 4.1% (893 of 21 805) among patients treated with no antiplatelet therapy, single antiplatelet therapy (SAPT), and DAPT, respectively (P < .001). In adjusted analyses after propensity score subclassification, both SAPT (odds ratio [OR], 1.13; 95% CI, 1.07-1.19) and DAPT (OR, 1.28; 95% CI, 1.14-1.42) were associated with increased risks of sICH. Prestroke antiplatelet medications were associated with lower odds of discharge mRS score of 2 or less compared with no medication (SAPT OR, 0.92; 95% CI, 0.90-0.95; DAPT OR, 0.94; 95% CI, 0.88-0.98). Results of a subgroup analysis of patients taking DAPT exposed to aspirin-clopidogrel vs aspirin-ticagrelor combination therapy were not significant (OR, 1.35; 95% CI, 0.84-1.86).

Conclusions and Relevance  Prestroke DAPT was associated with a significantly elevated risk of sICH among patients with ischemic stroke who were treated with thrombolysis; however, the absolute increase in risk was small. Patients exposed to antiplatelet medications did not have excess sICH compared with landmark trials, which demonstrated overall clinical benefit of thrombolysis therapy for acute ischemic stroke.

• Editorial
  Symptomatic Hemorrhage Risks in Stroke Thrombolysis
  JAMA Neurology

Full Text

Computed Tomography Perfusion Parameters Predictive of Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy in Patients With Cerebral Large Vessel Occlusion

So you predicted  sICH but did nothing to suggest how to prevent it from happening. USELESS! I'd have you all fired for incompetency!

Computed Tomography Perfusion Parameters Predictive of Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy in Patients With Cerebral Large Vessel Occlusion

Soichiro Abe,

Manabu Inoue,

Manabu Shirakawa,

Kazutaka Uchida,

Kiyofumi Yamada,

Yoji Kuramoto,

Satoshi Namitome,

Seigo Shindo,

Fumihiro Sakakibara,

Junichi Kouno,

… See all authors

Originally published4 Jun 2023https://doi.org/10.1161/SVIN.122.000747Stroke: Vascular and Interventional Neurology. 2023;3:e000747

• Other version(s) of this article

Abstract

Background

Hemorrhagic transformation after recanalization is a severe complication in patients with a large ischemic core due to cerebral large vessel occlusion. Risk assessment using perfusion imaging to predict hemorrhagic infarction has not been established. Thus, we aimed to investigate the association between perfusion imaging findings and hemorrhagic transformation in patients with acute cerebral large vessel occlusion who had undergone preoperative perfusion imaging evaluation and mechanical thrombectomy.

Methods

We enrolled consecutive patients who received mechanical thrombectomy after undergoing perfusion imaging for anterior large vessel occlusion from May 2019 to March 2022. The patients in whom recanalization were not achieved and who experienced procedure‐related bleeding were excluded. We investigated the predictors of symptomatic intracranial hemorrhage (sICH) by exploring preoperative perfusion imaging parameters (relative cerebral blood flow, relative cerebral blood volume, time of maximum concentration, and hypoperfusion index ratio).

Results

Among the 167 patients (median age 79 years, 47% female) enrolled, 63 (38%) and 14 (8%) patients had any intracranial hemorrhage and sICH (sICH group), respectively. The sICH group had a shorter puncture‐recanalization time than the non‐sICH group (median [interquartile range (IQR)]; 43 [34–55] versus 61 [37–88]; P=0.046), whereas the modified Rankin scale at 90 days showed a worse prognosis (median [IQR]; 5 [5–6] versus 3 [1–4]; P<0.01). All perfusion imaging parameters were significantly predicting the sICH group in multiple logistic regression analysis. The value of relative cerebral blood volume was the parameter most strongly associated with sICH in receiver operating characteristic curve analysis (area under the curve=0.90, 95% CI [0.83–0.98]; cutoff 43 mL; sensitivity, 86 %; specificity, 87%).

Conclusion

Among perfusion computed tomography parameters, relative cerebral blood volume is highly associated with sICH after mechanical thrombectomy for cerebral large vessel occlusion. In patients with low relative cerebral blood volume regions, the indication of mechanical thrombectomy should be carefully considered for postoperative intracranial hemorrhage.

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Occlusion Site Influence Symptomatic Hemorrhage Rate after Thrombectomy: A Daily Practice Study in 623 Stroke Patients

 You've got a lot of work to do to solve these problems. Just describing them is only the first step in your job. Your job is to solve stroke, in case your mentor didn't tell you that. Are you a leader or a mouse?

Occlusion Site Influence Symptomatic Hemorrhage Rate after Thrombectomy: A Daily Practice Study in 623 Stroke Patients

 

Cerebrovasc Dis

https://doi.org/10.1159/000512604

Abstract

Background: 

Comparison of symptomatic intracranial hemorrhage (SICH) rates between stroke patients treated with bridging therapy (BT) and primary mechanical thrombectomy (PMT) are scarce and difficult to interpret due to baseline differences between both populations.  

Methods: 

Retrospective analysis of patients with acute ischemic stroke treated with endovascular therapy (BT or PMT) was performed at our center between January 2010 and June 2017. 

Results: 

Six hundred twenty-three patients were included. Global SICH rate was 9% overall: 6.8% in the PMT group and 12.6% in the BT group(All too high). The following factors significantly associated with SICH after multivariate analysis: MCA occlusion (p: 0.047), stroke of unknown origin (p: 0.025), BT (p: 0.024), and procedural time over 65 min (p: 0.027). The following variables presented a statistically significant higher frequency in patients treated with PMT: atrial fibrillation (p: 0.005), anticoagulant medication (p < 0.001), wake-up strokes (p < 0.001), atherothrombotic etiology (p < 0.05), combined thrombectomy technique (p: 0.008), longer procedural times (p: 0.025), and favorable outcome at 3 months (p: 0.011). The following variables presented a statistically significant higher frequency in patients treated with BT: antiplatelet medication (p: 0.048), MCA occlusions (p: 0.017), cardioembolic etiology (p < 0.05), stent retriever/aspiration technique (p: 0.008), and SICH (p: 0.013). Patients with MCA occlusions had twice the risk of SICH after BT than after PMT (16.4 and 8.6%, p: 0.038).  

Conclusions: 

In this clinical series, the SICH rate was higher in patients treated with BT than in those treated with PMT. Relevant differences in baseline (related to IVT contraindications) were found between both groups. Randomized studies of BT versus PMT in populations with similar baseline characteristics might be of interest.

© 2021 S. Karger AG, Basel

Cabrera-Maqueda J.M.a,b · Alba-Isasi M.T.a · Díaz-Pérez J.c · Albert-Lacal L.a · Morales A.a · Parrilla G.c Author affiliations Keywords: Mechanical thrombectomySymptomatic intracranial hemorrhageBridging therapy