XVII. European Stroke Conference
Nice, France

Oral Session:

Acute stroke: treatment concepts II
Date: Wednesday 14 May 2008  
Time: 16:30 - 16:40 -  Room: Clio/Thalie
Chair: D. Karacostas, Greece and O. Busse, Germany

01
Treatment and outcome in basilar artery occlusion: results from the Basilar Artery International Cooperation Study (BASICS) registry
W.J.Schonewille    C.A.C.Wijman    P. Michel    C. Rueckert    C. Weimar    H.P.Mattle    S. Engelter    T. Baird    A. Algra    J. Kappelle
on behalf of the BASICS study group

University Medical Center Utrecht

THE NETHERLANDS

Background The optimal treatment for acute basilar artery occlusion is unknown. Methods BASICS is a prospective, observational, multi-center, international registry of consecutive patients presenting with an acute symptomatic and radiologically confirmed basilar artery occlusion. Results A total of 622 patients with basilar artery occlusion were included. Patients were treated with antithrombotics (AT) (n=184), intravenous thrombolysis (IVT) (n=80), intra-arterial (IA) therapy alone (n=290) or IVT followed by IA therapy (n=41). Twenty-seven patients did not receive any treatment. Patients in the IA therapy group were treated with IA thrombolysis (IAT) (n=179), IAT with mechanical thrombectomy (n=80) or mechanical thrombectomy alone (n=31). The table shows that age was similar in the treatment groups, whereas there were important differences in National Institute of Health Stroke Scale and time to treatment. A good outcome, defined as a modified Rankin score of 0-3 at one month, was found in 43% treated with IVT, in 37% treated with AT, in 36% treated with IVT+IA therapy and in 25% treated with IA therapy alone. Conclusion Intra-arterial therapy is the most frequently used treatment modality in BASICS. Our preliminary analyses do not suggest an obvious benefit of IA therapy as compared with IVT and show important differences between the treatment groups which hamper valid conclusions on the comparison of treatment effects. Treatment efficacy should therefore be assessed in a randomised controlled trial.

 
http://www.eurostroke.org/ni_graphics/t_aid3059.htm

Acute stroke: treatment concepts II
Date: Wednesday 14 May 2008  
Time: 16:40 - 16:50 -  Room: Clio/Thalie
Chair: D. Karacostas, Greece and O. Busse, Germany

02
Therapy of acute basilar artery occlusion: Intraarterial thrombolyis alone versus bridging therapy.
S. Nagel    P.D.Schellinger    M. Hartmann    E. Juettler    H.B.Huttner    P.R.Ringleb    S. Schwab    M. Koehrmann              
 

University of Heidelberg

GERMANY

Background: In contrast to the evidence based intravenous (IV) thrombolysis therapy for acute stroke in the anterior circulation, the best treatment regiment of basilar artery occlusion (BAO) is still unclear. We compared intraarterial (IA) thrombolysis with the combined approach of IV bridging with Abciximab and IA thrombolysis in an observational monocenter study. Methods: Between 1998 and 2006 patients with acute BAO were entered into a local database. Patients eligible for treatment received either IA thrombolysis with rtPA (max. 40mg) alone (IAF) or were treated with IV Abciximab (initial bolus of 0.25 mg/kg BW and subsequent infusion of 0.125 µg/kg BW/min over 12 h) and IA rtPA (Bridging therapy). Predefined outcome parameters were recanalisation of the basilar artery (BA) according to the TIMI criteria as well as survival and favourable outcome defined as a mRS of 0-3 at 3 months. Multivariate logistic regression modeling was used to identify independent predictors for recanalisation, survival and favourable outcome. Results: Of the patients with confirmed BAO, 75 patients were identified who received the full treatment protocols. Patients in the bridging group (n=43) had a better recanalisation rate (TIMI 2&3, 83.7% vs. 62.5%; p=0.03), a higher survival rate (58.1% vs. 25%; p=0.01) and a better chance of a favourable outcome (34.9% vs. 12.5%, p=0.02). Symptomatic intracerebral hemorrhage (sICH) rates were similar in both groups (14% in the bridging group vs. 18.8%; p=0.41). Independent predictors for recanalisation (TIMI 2&3) were age (OR=0.95, 0.91-0.99), atrial fibrillation (OR 6.53, 1.14-37.49) and bridging therapy (OR 3.37, 1.02-11.18). Independent prognostic factors for a favourable outcome were GCS at presentation (OR 1.24, 1.03-1.45) and the combination of bridging therapy with successful recanalisation (OR 3.744, 1.04-13.43). Conclusion: Bridging therapy for acute BAO with IV Abciximab and IA rtPA seems to be safe and yields higher recanalisation and improved survival rates as well as an overall better chance for a favourable outcome.

Acute stroke: treatment concepts II
Date: Wednesday 14 May 2008  
Time: 16:50 - 17:00 -  Room: Clio/Thalie
Chair: D. Karacostas, Greece and O. Busse, Germany

03
Staged Escalation Therapy in Acute Basilar Artery Occlusion: Intravenous Thrombolysis and On-Demand Consecutive Endovascular Mechanical Thrombectomy
T. Pfefferkorn    T.E.Mayer    C. Opherk    N. Peters    A. Straube    H.W.Pfister    M. Holtmannspötter    S. Müller-Schunk    M. Wiesmann    M. Dichgans
 

Klinikum Grosshadern, University of Munich

GERMANY

Background and Purpose: The prognosis of acute basilar artery occlusion (BAO) is poor if early recanalization is not achieved. Recanalization strategies include intravenous and intra-arterial thrombolysis (IVT and IAT) as well as endovascular mechanical thrombectomy (EMT). The combination of IVT with consecutive on-demand EMT may allow for early treatment initiation with high recanalization rates but has never been systematically tested in patients with BAO. Patients and Methods: Starting in January 2006, we treated all eligible patients with acute BAO admitted to our academic stroke center or one of our cooperating community hospitals following a standardized protocol combining IVT with consecutive on-demand EMT. Inclusion criteria were: 1) presence of pre-defined symptoms clearly suggestive of BAO, 2) exclusion of intracerebral hemorrhage on CT scan, 3) evidence of BAO on CT angiography (CTA), 4) start of therapy within six hours after symptom onset, and 5) no contraindications for IVT. If CTA showed persistent BAO after IVT, EMT was performed. Results: Since January 2006, 20 patients have been treated. All patients received IVT, in nine of them EMT became necessary due to persistent BAO. Final recanalization was achieved in 18 patients. Three months after therapy, 14 of 20 patients were still alive, nine of them had a good outcome (modified Rankin Score </=2). Conclusions: Our data suggest that the combination of IVT with on-demand consecutive EMT in BAO is feasible, allows for early treatment and provides excellent recanalization rates.

Acute stroke: treatment concepts II
Date: Wednesday 14 May 2008  
Time: 17:00 - 17:10 -  Room: Clio/Thalie
Chair: D. Karacostas, Greece and O. Busse, Germany

04
Ultrasound assisted thrombolysis in acute basilar artery thrombosis
V.K.Sharma    H.L.Teoh    B.KC.Ong    B.PL.Chan                                          
 

National University Hospital

SINGAPORE

Background: Intravenously-administered tissue plasminogen activator (IV-TPA) has been approved recently in Singapore for acute ischemic stroke. Continuous exposure of clot to 2-MHz pulsed-wave transcranial Doppler (TCD) ultrasound during IV-TPA infusion is known to augment thrombolysis. Acute Basilar artery thrombosis (BAT) is a catastrophic disease in majority & the survivors may be severely impaired. We aimed to determine the feasibility, safety & efficacy of ultrasound-assisted thrombolysis in our patients with acute BAT. Methods: Consecutive patients with acute BAT were treated with standard IV-tPA and continuously monitored with 2-MHz TCD according to the CLOTBUST protocol. Arterial recanalization was determined with Thrombolysis in Brain Ischemia (TIBI) flow-grading system. Safety & efficacy of ultrasound-assisted thrombolysis were assessed by rates of symptomatic intracranial hemorrhage (sICH) & functional recovery at 3 month, respectively. Results: 12 consecutive patients (mean age 58years, 8men) were included. Mean-time elapsed between symptom-onset & presentation to emergency room was 86minutes (range 50-140minutes) while the mean interval between symptom-onset to IV-TPA bolus was 164minutes (range 125-180minutes). Mean NIHSS score was 13 points (range 7 to 24). Partial or complete recanalization with reduction in the stroke severity was noted in 9 out of the 12 patients during IV-TPA infusion (mean change in NIHSS= 7 points; range 3-20 points). None of our patients developed sICH while 11 patients demonstrated good functional outcome at 1-month. Discussion: Our preliminary study demonstrates the feasibility, safety & efficacy of ultrasound-assisted thrombolysis in acute basilar artery thrombosis in Singapore. Continuous TCD-monitoring during IV-TPA infusion provides real-time information & enhances thrombolysis acute basilar artery thrombosis.

Acute stroke: treatment concepts II
Date: Wednesday 14 May 2008  
Time: 17:10 - 17:20 -  Room: Clio/Thalie
Chair: D. Karacostas, Greece and O. Busse, Germany

05
INTRA-ARTERIAL AND INTRAVENOUS THROMBOLYSIS IN ACUTE ISCHEMIC STROKE FROM CAROTID “T” OCCLUSION
P. Nencini    I. Romani    S. Mangiafico    V. Palumbo    M. Nesi    M. Cellerini    A. Rosselli    D. Inzitari              
for the Careggi Stroke Team

University of Florence

ITALY

Background: Outcome in acute ischemic stroke from internal carotid artery occlusion is poor with high mortality or severe disability. We evaluated if intra-arterial (IAT) or intravenous thrombolysis (IVT) may influence outcome. Methods: From February 2004 to December 2007, 48 patients with acute internal carotid artery “T” occlusion were admitted to two Hospitals in Florence, Italy. All patients underwent screening for IVT (SITS-MOST protocol), colour duplex sonography or cerebral angiography and a 3-month mRankin scale (mRS). Results: Thirty-two patients (male 43%, mean age 66 years, mean NIHSS 20) were treated with IAT (4 had IAT+IVT) within 6 hours from symptom onset; 7 patients (male 14%, mean age 73 years, mean NIHSS 19) with IVT within 3 hours from symptom onset; and 9 patients (male 66%, mean age 67 years, mean NIHSS 20) had standard treatment. Thirteen out of 32 (42%) IAT patients had a good outcome (mRS 0-3) compared with 1 patient in the IVT group and 1 in the standard treatment group (p=0.096). Four patients were independent (mRS 0-2) at 3 months, all were treated with intra-arterial approach. The 3-month mortality rate was 25% in IAT, 28% in IVT and 44% in the standard group, respectively (p=0.544). Symptomatic haemorrhage occurred only in IAT group (22% of patients). Factors associated with increased mortality were age (p=0.026) and the presence of extensive early ischemic changes (p=0.039). The presence of collaterals, baseline NIHSS and delay on treatment did not seem to affect the risk of death. Conclusions: The prognosis of ischemic stroke due to internal carotid artery “T” occlusion remains severe. Our data may suggest a favourable effect on the intra-arterial approach in younger patients with good scans. More data are needed to confirm this hypothesis.

Acute stroke: treatment concepts II
Date: Wednesday 14 May 2008  
Time: 17:20 - 17:30 -  Room: Clio/Thalie
Chair: D. Karacostas, Greece and O. Busse, Germany

06
Routine Combined Intra-Venous and Intra-Arterial Thrombolysis in Acute Stroke Patients With Arterial Occlusion
M. Mazighi    J.M.Serfati     J . Labreuche     E. Meseguer     P.C.Lavallée     L. Cabrejo     T. Slaoui     I.F.Klein     J.P.Laissy     P. Amarenco
 

Hopital Bichat

FRANCE

Background—Intravenous (IV) thrombolysis efficacy is reduced in brain infarction (BI) with documented arterial occlusion. We report a consecutive series of acute stroke patients with arterial occlusion treated by a systematic combined IV and intra-arterial (IA) approach. Methods—A total of 265 consecutive BI patients were treated with rt-PA at Bichat University Hospital between February 2002 and December 2007. Since April 2007, patients with a documented arterial occlusion were treated by a combined IV and IA approach. Patients received 0.6 mg rt-PA IV and were systematically transferred to the cath lab for IA administration, if the arterial occlusion remained (additional rt-PA was administered via a microcatheter at the site of the thrombus up to a total dose of 22 mg). Results—Sixteen patients were treated by a combined IV and IA approach, representing 24% of 67 rt-PA-treated patients since April 2007. The sex ratio (M:F) was 10/6 with a median age of 69 (interquartile range (IQR), 61-79) and median of baseline NIHSS score of 17 (IQR, 12-21). Arterial site occlusion included middle cerebral artery: 94%; internal carotid artery (“T” occlusion): 19%; basilar artery: 6%. The median delay from symptoms onset was 131 minutes for IV administration and 188 minutes for IA administration. Eighty eight % achieved vessel recanalization, among them 64% had complete recanalization. The rate of symptomatic intracranial hemorrhage was 13%. Six(38%) patients had a good outcome (mRS≤2) and 4 (25%) deaths occurred (one procedure related, one stroke recurrence and two non-stroke related). Conclusions—Combined IV and IA thrombolysis approach achieved high recanalization rates, but long-term follow-up and randomized controlled trial are required to assess its clinical benefit-risk ratio.

Acute stroke: treatment concepts II
Date: Wednesday 14 May 2008  
Time: 17:30 - 17:40 -  Room: Clio/Thalie
Chair: D. Karacostas, Greece and O. Busse, Germany

07
Favourable ASPECTS scores predict good outcome in Multi MERCI
M.D.Hill    H. Lutsep    N. Barman    M. Marks    G. Nesbitt    T. Jovin                            
for the MultiMerci Registry

University of Calgary

CANADA

Background Mechanical thrombolysis with the Merci Retriever is an increasingly accepted procedure in North America. We sought to assess the baseline ASPECTS score as a predictor of favourable outcome among patients treated with the Merci Retriever. Methods Patients included those with anterior circulation strokes in the Multi MERCI multi-site, non-randomized trial of acute ischemic stroke patients treated with endovascular mechanical thrombus retrieval within 8 hours of symptom onset. CT scan images were collected centrally. A panel of readers (3 neurologists and 2 neuroradiologists) reviewed the scans and scored them on ASPECTS. The panel was blinded to all clinical data except for the side of the stroke. Baseline data and outcomes were compared according to ASPECTS ≤7 vs. >7 and ASPECTS ≤4 and > 4. (ASPECTS=4 ~ 1/3rd MCA rule) Results Scans were available in 142 patients who had a median age 72, 58% female, median baseline NIHSS of 18. Eighty patients (56%) had ASPECTS ≤7 and 26 patients (18%) had ASPECTS ≤4 . A greater number of patients in the unfavourable (≤7) ASPECTS group had carotid occlusions (44%) compared to the favourable ASPECTS group (26%) (p=0.079). When ASPECTS was dichotomized at 7, no difference in death, good outcome or hemorrhage was observed between groups. ASPECTS ≤4 was associated with a 2.5-fold increase in the risk of parenchymal hematoma (RR 2.55 CI95 1.2-5.4) and symptomatic ICH (RR 3.7 CI95 1.2-11.3). Among patients with CT-to-arterial puncture time < 2 hours, an unfavourable ASPECTS ≤7 predicted a halving of the chance of doing well from 62% to 33% (RR = 0.54, CI95 0.32-0.92) and an infinite increase in the risk of symptomatic ICH (10.6% vs. 0%). Discussion In this cohort of acute stroke patients undergoing intra-arterial intervention, very low ASPECTS score (≤4) were predictive of an increased risk of parenchymal hematoma and SICH. Low ASPECTS scores (≤7) obtained within 2 hours of the time of treatment were predictive of lower probability of good outcome, and increased risk of SICH.

Acute stroke: treatment concepts II
Date: Wednesday 14 May 2008  
Time: 17:40 - 17:50 -  Room: Clio/Thalie
Chair: D. Karacostas, Greece and O. Busse, Germany

08
The Penumbra II Trial: Safety and Effectiveness of a Novel Device for Clot Extraction in Acute Ischemic Stroke
T.E.Mayer                                                               
 

Friedrich Schiller Universitaet, Jena

GERMANY

Background We investigated a mechanical device, which was designed to be more efficient than first generation retriever devices or local intraarterial fibrinolysis and to be compatible to previous systemic rtPA therapy. The Penumbra System (PS) is a novel device platform which combines local thrombus aspiration and retraction for the recanalization of cerebral arteries in acute stroke. Methods A total of 125 patients were enrolled at 24 international centers in this prospective, phase 2, single arm trial to assess the safety and effectiveness of the PS. Main entry criteria were NIH Stroke Scale (NIHSS) score > 8, presentation within 8 hours of symptom onset, and an occlusion of a major intracranial vessel (TIMI 0 or 1). Patients who presented within 3 hours from symptom onset must have been ineligible for or refractory to rtPA therapy. Primary endpoints were revascularization of the target vessel and incidence of procedural serious adverse events (SAEs). If there was CT evidence of an intracranial haemorrhage (ICH), it was defined symptomatic in case of a > 4 point deterioration on the NIHSS. Angiographic results were adjudicated by an independent Core Laboratory. Results Mean baseline values at enrollment were: age 64 years and NIHSS score 17.6 (range 8 to 34). After the use of the PS, 82% of the treated vessels were revascularized (TIMI 2 or 3). Four procedural SAEs (3.2%) were reported. Fourteen (11.2%) patients were found to have symptomatic ICH at 24 hours. All cause mortality was 26.4% at 30 days, and 25% of the patients had a 90 day modified Rankin Scale (mRS) of < 2. Discussion These first results suggest that the PS may allow safe and effective revascularization in patients experiencing ischemic stroke. The combination of a microretriever and local aspiration seems to be beneficial in large vessel thromboembolism without or after failed systemic fibrinolysis.

Acute stroke: treatment concepts II
Date: Wednesday 14 May 2008  
Time: 17:50 - 18:00 -  Room: Clio/Thalie
Chair: D. Karacostas, Greece and O. Busse, Germany

09
TNK Induces Faster MCA Recanalization and Better Short-term Outcome Than Native tPA. The TNK-TPA Reperfusion Stroke Study
C.A.Molina    M. Ribo    M. Rubiera    E. Santamarina    R. Delgado-Mederos    O. Maisterra    G. Ortega    L. Dinia    J. Montaner    J. Alvarez-Sabin
 

Hospital Vall d´Hebron. Barcelona

SPAIN

Aim: We aimed to compare the effects of two thrombolytic regimen (TNK vs standard tPA) on MCA recanalization, ischemic tissue evolution and stroke outcome. Methods: We evaluated 122 consecutive stroke patients due to MCA occlusion who fulfilled criteria for iv thrombolysis. Patients were allocated to receive standard iv tPA 0.9mg/Kg (10% bolus, 90% 1-h infusion) or iv TNK 0.4 mg/Kg (bolus), All patients underwent a non-contrast CT scan and/or MRI before and at 36-48h of treatment. Site of arterial occlusion before treatment and 2-hour recanalization was assessed with TCD. NIHSS scores were obtained at baseline and 24h. Symptomatic and asymptomatic ICH were assessed on CT scan at 24-36h Results: Median pre-bolus NIHSS score was 17. Eighty-five (69%) patients had a proximal and 37 (31%) a distal MCA occlusion. Eighty (66%) patients received tPA and 42 (33%) TNK. Stroke severity, time to treatment, location of MCA occlusion and extend of early ischemic (ASPECTS) were similar in both groups. At 2h of treatment, recanalization was higher (p=0.028) in TNK (n=29/69%) as compared to tPA (n=43/53%) group. Complete recanalization at 2h was seen in 18 (42.4%) and 27 (33.4%) patients treated with TNK and tPA, respectively (p=0.014). The time to beginning of recanalization after bolus was comparable in TNK (27±19 min) and tPA (35±24 min) groups (p=0.11). At 36-48h, the infarct size on CT was smaller (p=0.001) in TNK compared with tPA treated patients. SICH occurred in one (2.3%) and 3 (3.7%) TNK and tPA patients, respectively. Asymptomatic ICH on 24-36h CT was seen in 28% of TNK and 21% of tPA treated patients (p=0.089). At 24h, 63% and 51% of TNK and tPA, improved > 4 points in the NHSS score. TNK increased in 2.5-fold the rate of dramatic clinical recovery at 24h as compared to tPA (24.5% vs 11%). Conclusion: Compared to native tPA, TNK (0.4 mg/Kg) administration is associated with faster and more complete MCA recanalization, better short-term outcome without increasing the risk of SICH.