Acute ischemic stroke: Targeting arterial occlusion and revascularization for individualized treatment decisions.

摘要

Large vessel occlusion in acute ischemic stroke remains a frequent stroke mechanism and is related to severe strokes, poorer outcome and higher mortality rates. Knowledge regarding the location, characteristics of the clot and underlying, arterial pathology and the chance of recanalization is essential to guide acute stroke management during the pre-hospital and early hospital phase (within 24hours). A more individualized triage, diagnostic and therapeutic approach based on the occlusion and recanalization parameters may improve clinical outcome on short and long term. Based on the prospectively collected dataregistry (ASTRAL) from the University Hospital Lausanne (CHUV:2003-2015) different research projects were performed.;1.Large vessel occlusions in ischemic strokes We detected clinical and radiological predictors for the presence of arterial clots, different clot sites and the affected arterial circulation (anterior vs. posterior) in patients arriving within 12h after symptom onset. From this data, a predictive, statistical model (i.c. ASTRAL-occlusion score) was developed to predict the presence of major intracranial occlusion(s) by using variables easily assessable in the pre-hospital phase.;2. Arterial recanalization of large vessel occlusions First, we identified independent predictors of arterial recanalization (at 12-48hours) among multiple demographic, clinical, metabolic and radiological variables and this independent of the treatment strategy applied (untreated, IVT and/or EVT). Second, a subgroup analysis was performed for two special patient populations: untreated and IVT-treated AIS patients. This knowledge has been used to develop and internally validate an easy to use score (i.c. ASTRAL-R score) for the prediction of non-recanalization after IV thrombolysis in AIS patients. The impact of adding frequently available radiological items such as the clot burden, collateral patency and early ischemic changes on CT using the ASPECTS, has improved the initial ASTRAL-R score for its diagnostic performance.;3. Eligibility for acute stroke treatments Finally, we determined the frequency of potentially eligible patients for IVT and EVT in a real-world clinical setting. These frequencies were compared to eligibility based on the more strict AHA/ASA guidelines. In addition, we identified some predictors for EVT-eligibility based on the AHA/ASA guidelines separately.