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Title: Prognostic significance of treatment ischemic stroke by mechanical thrombectomy taking into account the systolic and diastolic heart failure

Abstract:

The aim of the study was to determine the incidence of the early effects of treatment of ischemic stroke by mechanical thrombectomy (artery recanalization, no bleeding after treatment, at least a small early improvement aftertreatment, a significant early improvement after treatment); late effects of treatment of ischemic stroke by the mechanical thrombectomy ( mortality at day 90., complete recovery at day 90.); and assessment which of analyzed demographic, biochemical and clinical indicators, including systolic and diastolic heart failure affect the early and late effects of treatment. .The study was conducted in consecutive patients with a diagnosis of ischemic stroke treated at the Stroke Unit, Department of Neurology at the University Hospital in Krakow, from January 1 2013. until December 31 2015.The inclusion criteria were: ischemic stroke (diagnose based on the definition of the WHO 1976.), time of stroke onset to procedure up to 8 hours and normal cognitive status enabling to consent to treatment with mechanical thrombectomy.Every person in whom mechanical thrombectomy was performed had to meet the inclusion and exclusion criteria. The treatment protocol was approved by the Bioethical Committee of Jagiellonian University.On admission to the Stroke Unit the following tests were performed: head computed tomography and perfusion computed tomography and computed tomography angiography of the intra- and extracranial arteries; general examination with the assessment of NYHA heart failure scale; panel of biochemical tests in accordance with the recommendations of ESO (including the glucose level); assessment of neurological status by the NIHSS scale; body temperature and blood pressure measurement. Among all patients following risk factors were identified: hypertension, diabetes, coronary heart disease, atrial fibrillation and obesity. Digital subtraction angiography was performed after mechanical trombectomy. Fasting glucose level, platelet count and complete blood count ware tested on the first post-procedural day. Control computed tomography scan of the head was performed 24 hours after treatment. During the hospitalization the following tests were performed: carotid arteries ultrasound, transcranial Doppler ultrasound, transthoracic echocardiography, 24-hour monitoring of the heart rhythm, and if indicated, transesophageal echocardiography and blood tests for hypercoagulopathy and the presence of autoantibodies. On discharge, neurological deficit was assessed in NIHSS scale and own five-point scale assessing of the early results of treatment. Three months after stroke onset neurological deficit was assessed using the Barthel Index. ; The information obtained were stored in a computer database.The results of the study are presented as mean values and standard deviations. For comparison, the distribution of categorical variables between groups was used chi2 test, and quantitative variables - tests: Student's t (normal distribution) and Mann-Whitney test (abnormal distribution). Correlations were tested using Spearman test. In order to verify whether test variables are independent of other determinants of early and late effects of treatment and performed multifactorial linear regression analysis and logistic regression. The threshold for statistical significance was set at < 0,05. To perform these evaluations the statistical package "Statistica. version 9" was used.During the study period, from January the 1st, 2013. until December the31st 2015., the stroke unit admitted 1107 patients with a diagnosis of ischemic stroke. Causative treatment was performed in 258 patients. Mechanical thrombectomy was performed among 66 patients, 33 men and 33 women (mean age 65.8 ± 13.1 years). The mean score in the NIHSS scale was 15.3 ± 4.4 points. Etiology of ischemic stroke has not been established in 30 patients (45%). Among those with established etiology the most cases were diagnosed with cardio-embolic stroke (28 patients, 42.4%). Stroke caused by large vessel disease was found in 6 patients (9.1%). In two cases, the stroke was caused by the dissection of the arteries (3.0%). Transthoracic echocardiography to assess systolic and diastolic functions was performed in 55 patients (83.3%). Systolic dysfunction was observed in 5 patients, and among patients with normal systolic function, diastolic dysfunction was observed in 7 patients. In 9 cases echocardiogram was not performed because of severe neurological condition (6 patients), or the lack of consent (3 patients).In 40 patients (60.6%), treatment with mechanical thrombectomy was preceded by the administration of rt-PAIV. In other cases, rt-PAIV was not given due to exceeded therapeutic window (15 persons, 22.7%); INR increase above 1.7 (n = 7, 10.6%); gastrointestinal bleeding (n = 1, 1.5%); surgery during the previous two weeks (n = 1, 1.5%); iliac artery puncture one day prior stroke onset (n = 1, 1.5%); subarachnoid hemorrhage and clipped aneurysm (n = 1, 1.5%). Rt-PA intra-arterially was administered during endovascular procedure in 4 patients (6.2%). Stenting of carotid artery due to critical stenosis was performed in 4 cases.In all study participants early and late effects of treatment were assessed. ; Three points in TICI scale (complete recanalization) was obtained in 23 cases (34.8%). In 32 patients, there was no hemorrhagic transformation 24 hours after the procedure estimated using ECASS 1 scale. 37 patients (56.5%) obtained a significant improvement or complete recovery at discharge. In 9 (13.6%) patients - a slight improvement was observed. In 7 (10.6%) cases there was no change in neurological status, and in 3 patients (4.5%) neurological deficit declined significanty. Mortality rate at day 90. was 18.2% ( 12 patients) out of which 10 died during hospitalization. Among the remaining 54 people at day 90. 35 (64.8%) patients received 80-100 points in the Barthel Index. Five patients (9.3%) achieved 0 to 19 points, two people received 20 to 39 points, 6 patients - 40 to 59 points and 6 patients - 60 do79 points.Statistical analysis does not allow to identify factors affecting the complete recanalization after the thrombectomy procedure. In the logistic regression model taking into account age, gender, result in the NIHSS scale on admission and the presence of coronary heart disease, lower score in NIHSS scale affected lack of hemorrhagic transformation in the control CT scan 24 hours after stroke onset. The logistic regression model taking into account age, gender, glucose level on admission and the white blood count on the first post-procedural day has shown that the lower glucose level and white blood count lower than 10 000 in the first post-procedural day increase the chances for early small improvement. The logistic regression model taking into account age, gender, time from stroke onset to groin puncture, glucose level on admission and white blood count in the first post-procedural day demonstrated that the shorter the time from onset to the groin puncture and the white blood count lower than 10 000 increase the chances for early significant improvement. The logistic regression model taking into account age, sex, glucose level on admission and white blood count on the first post-procedural day has shown that higher glucose level on admission and white blood count lower than 10 000 in the first post-procedural day increase the risk of death up to day 90. Independent factors determining the total recovery on day 90. was not identified.Factors determining the prognosis after thrombectomy procedure depending on tested predictive model are: glucose at admission, white blood count in the first post-proceduralday, neurological deficit in the NIHSS scale and the time from onset to groin puncture.Among the tested risk factors, biochemical and clinical markers, the following indicators did not affect early prognosis in the studied models: age, gender, hypertension history, diabetes, coronary heart disease, atrial fibrillation, BMI, systolic and diastolic blood pressure at admission, body temperature at admission, platelet count the first post-procedural day and systolic and diastolic heart failure. The late outcome was not affected by: age, sex, hypertension, diabetes, coronary heart disease, atrial fibrillation, BMI, systolic and diastolic blood pressure at admission, body temperature at admission, platelet count the first post-procedural day, systolic and diastolic heart failure, cerebral artery recanalization after the treatment and presence of hemorrhagic transformation 24 hours after procedure.

Place of publishing:

Kraków

Level of degree:

2 - studia doktoranckie

Degree discipline:

neurologia

Degree grantor:

Uniwersytet Jagielloński. Collegium Medicum. Wydział Lekarski.

Promoter:

Agnieszka Słowik

Date issued:

2016

Format:

application/pdf

Identifier:

oai:dl.cm-uj.krakow.pl:4183

Call number:

ZB-126653

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Language:

pol

Access rights:

tylko w bibliotece

Location of original object:

Biblioteka Medyczna Uniwersytetu Jagiellońskiego- Collegium Medicum

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Last modified:

May 24, 2021

In our library since:

Oct 16, 2017

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ZB-126653 May 24, 2021
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