Objectives: To review some factors related to neurological functional recovery outcome in the treatment of acute ischemic stroke by the solitaire device. Subjects and methods: A prospective study and case series were conducted on 104 patients at People’s Hospital 115 from 4 - 2014 to 9 - 2016.
Trang 1REVIEW SOME FACTORS RELATED TO NEUROLOGICAL
FUNCTIONAL RECOVERY OUTCOME IN THE TREATMENT
OF ACUTE ISCHEMIC STROKE BY THE SOLITAIRE DEVICE
Vu Viet Lanh*; Phan Viet Nga**
SUMMARY
Objectives: To review some factors related to neurological functional recovery outcome in the treatment of acute ischemic stroke by the solitaire device Subjects and methods: A prospective study and case series were conducted on 104 patients at People ’ s Hospital 115 from 4 - 2014 to
9 - 2016 Results: The age group greater than or equal 70 had worse neurological functional outcome (23.5%) than the group less 70 years old (55.2%), statistically significant difference (p < 0.03) The good recanalization group had better neurological functional outcomes (59.7%) than that without good recanalization (22.2%), the difference was statistically significant (p < 0.05) The group of severe stroke patients (NIHSS > 15) with better neurological functional outcomes (39.7%) was less than that at the mild and moderate level (NIHSS ≤ 15), statistically significant difference (p < 0.05) The symptomatic incranial hemorrhage patients with bad neurological functional outcome (mRS 3 - 6) (100%) were higher than those with asymptomatic incranial hemorrhage (42.9%), statistically significant difference (p < 0.05) Conclusions: Such factors as revascularization, severe stroke levels, symptomatic incranial hemorrhage related to neurological functional recovery outcome
* Keywords: Acute ischemic stroke; Revascularization; Neurological functional recovery outcome
INTRODUCTION
Stroke is a common disease in the
world as well as Vietnam It is the third
most common cause of death after heart
disease and cancer and is the single reason
for permenant disability More than 700,000
new strokes occur each year in the United
States alone, accounting for more than
45 billion dollars in medical expenses,
rehabilitation costs, and loss of employment
[3]
Stroke is a pathological process Therein,
the cerebral artery is narrowed or occluded
The circulating blood volume is severely reduced, the function of area of the brain
is disordered [1] A cerebral infarction can occur for a few minutes as the circulating blood volume is reduced so it is rapid revascularization and restoration of circulation
In 1996, Food and Drug Administration (FDA) approved the administration of intravenous (IV) recombinant tissue plasminogen activator (rt-PA) within
3 hours of symptoms onset for the treatment
of patients with acute ischemic stroke
* Thaibinh General Hospital
** 103 Military Hospital
Corresponding author: Phan Viet Nga (dr.vietnga@gmail.com)
Date received: 11/07/2017
Date accepted: 08/08/2017
Trang 2Due to the time limitation and contraindications
to intravenous tissue-type plasminogen
activator (IV tPA), < 10% of patients with
stroke receive the treatment, even in
well-organized stroke networks Furthermore,
IV tPA recanalizes only 40% of large vessel
occlusions in patients with acute stroke
during the first hours after administration
with even lower rates of revascularization
for proximal arterial occlusions such as
the terminal internal carotid artery Thus,
faster and more effective approaches to
reperfusion are needed [4] Clinical results
have shown that mechanical devices for
clot removal provide an alternative treatment
option to patients with stroke who are
ineligible for thrombolytic therapy The
solitaire device has received US Food
and Drug Administration clearance for use
in the revascularization of patients with acute
ischemic stroke secondary to intracranial
large vessel occlusive disease In Vietnam,
this approach has been deployed in some
hospitals and received good results
Therefore, we have studied this topic
to aim: Review some factors related to
neurological functional recovery outcome
in the treatment of acute ischemic stroke
by the solitaire device
SUBJECTS AND METHODS
1 Subjects
We conducted a prospective study to
evaluate all consecutive patients with
ischemic stroke, who were treated from
April, 2014 to September, 2016 at
People’s Hospital 115 Patients had
received Solitaire device as the first-choice
device to restore blood flow Patients had a intracranial and terminus internal carotid artery (ICA), first and second segments
of the middle cerebral artery (MCA), basilar artery (BA) and first segment posterior cerebral artery (PCA), patients were refractory to intrarvenous IV tPA or the patient had contraindications for systemic thrombolysis within 6 hours from onset stroke symptoms
* Inclusion criteria:
- No hemorrhage image on CT-scanner
or MRI
- From the onset of stroke symptoms
to treatment ≤ 6 hours
- Patients have proximal vessel large arterial occlusion: Intracranial and terminus internal carotid artery (ICA), first and second segments of the middle cerebral artery (MCA), basilar artery (BA) and first segment posterior cerebral artery (PCA)
- Patients visit the hospital > 4.5 hours after the onset of stroke symptoms or ineligibility for or failure to respond to intravenous rt-PA
- Patients and their families agree to treat
* Exclusion criteria:
- The exact time of onset stroke symptoms
is unknown
- Systolic blood pressure ≥ 185 mmHg
or diastolic blood pressure ≥ 110 mmHg is uncompensated
- Platelet below 100,000/mm3 Hematocit below 25%
- Blood glucose < 50 mg/dL (2.8 mmol/L)
or > 400 mg/dL (22.2 mmol/L)
Trang 3- Activated partial thromboplastin time
(aPTT) > 50 seconds Anticoagulation with
IRN (International Normal Ratio) > 3.0 or
administration of heparin within the early
48 hours
- Ischemic infarction occurs in more than
a third of the middle cerebral artery territory
on CT-scanner
2 Methods
Prospective study and case series
RESULTS AND DISCUSSIONS
1 Age
Table 1: Age factor related to the neurological functional revovery outcome
Number (n = 52)
Rate (%)
Number (n = 52)
Rate (%)
OR 95%CI
p
Age
4.00 (1.2 - 13.2)
0.03
The age group greater than or equal 70 had worse neurological functional outcome (23.5%) than the group less 70 years old (55.2%), statistically significant difference (p < 0.03) According to the medical literature, age was a constant risk factor The higher age it is, the more the accumulation of risk factors is (vessel disease, atherosclerosis…) In the studies, the elderly had worse neurological functional revovery outcome than the younger [6] However, there is currently no evidence of high levels of (A-level) confidence in the relationship between age and benefit of the intervention The main cause may be the limited number of elderly patients in the intervention studies
2 Recanalirization
Table 2: Recanalization related to neurological functional recovery outcome
TICI
OR
0.19
The recanalization group had better neurological functional outcome (59.7%) than the group without good recanalization (22.2%), the defference was statistically significant (p < 0.05)
According to Joung Ho Rha (2007), there was a relationship between cerebral vascular reassessment and the level of neurological rehabilitation in patients with acute brain stroke [7] Therefore, it was necessary to re-circulate blood vessels early to increase cerebral circulation and to increase the level of neurological rehabilitation
Trang 43 The severity of stroke according to the NIHSS scale
Table 3: The severity of stroke according to NIHSS scale related to neurological
function recovery outcome
NIHSS
3.45 (1.46 - 8.15)
0.007
The number of severity stroke patients (NIHSS > 15) had worse neurological functional outcome (39.7%) than those at mid and moderate level (NIHSS ≤ 15), statistically significant deference (p < 0.05)
Currently, there are many scales to review severe stroke levels Therein, the NIHSS scale has high specificity and sensitivity, severe stroke levels is directly associated with high NIHSS score [10] The NIHSS score scale was capable of predicting neurological recovery in acute stroke patients Patients with NIHSS score > 15 are at risk of disability and poor neurological recovery [5]
4 Symptomatic incranial hemorrhage
Table 4: Symptomatic incranial hemorrhage related to neurological functional
recovery outcome
Symptomatic
incranial hemorrhage Number
(n = 52)
Rate (%)
Number (n = 52)
Rate (%)
0.42 (0.33 - 0.54)
> 0.05
In the study, the symptomatic incranial hemorrhage patients group without good neurological functional outcome (mRS 3 - 6) (100%) was higher than that with asymptomatic incranial hemorrhage patients group (42.9%), statistically significant difference (p < 0.05)
According to Saver and Lanberg (2007), symptomatic incranial hemorrhage was the most serious complications leading to high mortality and disability after intravenous thrombolytic and intervention therapy [8, 9]
Trang 55 Multivariate regression statistical analysis
Table 5: Multivariate regression statistical analysis of risk factors related to neurological
function recovery outcome
< 70 Age
< 2 TICI
No Symptomatic incranial
≤ 15 NIHSS
Multivariate regression statistical analysis showed that factors related to neurological functional recovery outcome include age group, revascularization, symptomatic incranial hemorrhage, severe stroke leves) Besides, no good revascularization group (TICI 0 - 2A), symptomatic incranial hemorrhage group, severity stroke group (NIHSS > 15) associated with impaired neurological functional rehabilitation (mRS 3 - 6)
CONCLUSIONS
- Simple variable statistical analysis:
+ The risk factors related to good
neurological functional outcome: the age
group less than 70, good revascularization
(TICI ≥ 2B), mid and moderate stroke
(NIHSS ≤ 15)
+ The risk factors related to no good
neurological functional outcome: the
age group greater than 70, no good
revascularization (TICI 0 -2A), severity
stroke (NIHSS > 15) and symptomatic
incranial hemorrhage
- Multivariate regression statistical analysis
revealed that factors related to neurological
functional recovery outcome are age group,
revascularization, symptomatic incranial
hemorrhage, severe stroke levels); no good revascularization group (TICI 0 - 2A), symptomatic incranial hemorrhage group, severity stroke group (NIHSS > 15) associated with impaired neurological functional rehabilitation (mRS 3 - 6)
REFERENCES
1 Nguyễn Văn Chương Thực hành thần
kinh tập III: Bệnh học thần kinh Nhà xuất bản
Y học 2005, tr.7-73
2 Phạm Nguyên Bình Đánh giá tính an
toàn và hiệu quả phương pháp lấy huyết khối bằng dụng cụ cơ học solitaire ở bệnh nhân đột quỵ nhồi máu não Luận văn Thạc sỹ
Y học Trường Đại học Y Dược Thành phố
Hồ Chí Minh 2013
3 Perry P Ng, Randall T Higashida, Sean
P Cullen et al Intraarterial thrombolysis trials
Trang 6in acute ischemic stroke J Vasc Interv Radiol
2004, 15, S77-S85
4 Antoni Davalos, Victor Mendes Peria,
Rene Chapot et al Retrospective multicenter
study of solitaire FR for revascularization in
the treatment of acute ischemic stroke Stroke
2012, 43
5 Marian Muchada, Marta Rubiera Baseline
National Institutes of Health Stroke Scale -
adjusted time window for intravenous tisue -
type plasminogen activator in acute ischemic
stroke Stroke 2014, 45, pp.1059-1063
6 Messeguer E., Labreuche J., Olive J.M
et al Determinants of outcome and safety of
intervenous tr-PA therapy in the older: a
clinical registry study and systematic review
Age and Ageing 2008, 37, pp.107-111
7 Rha J.H, Shaver J.L The impact of
recanalization on ischemic stroke outcome: a meta - analysis Stroke 2007, 38, pp.976-973
8 Maarten G Lansberg, Gregory W Albers Christine Symptomatic intracerebral
hemorrhage following thrombolytic therapy for acute ischemic stroke: A review of the risk fators Cerebrovasc Dis 2007, 24, pp.1-10
9 Jeffrey L Saver Intra-arterial fibrinolysis
for acute ischemic stroke: The massage of Melts Stroke 2007, 38, pp.2627-2628
10 Maurizio Paciaroni, Giancarlo Agnelli, Francesco Corea et al Early hemorrhage
transformation of brain infarction: rate, predictive factors and influence on clinical outcome Results of a prospective multicenter study Stroke 2008, 39, pp.2249-2256