1. Table 1:
Table 2:
Non Therapeutic Angiograms in Acute Ischemic Stroke Patients Being Considered for Endovascular Treatment Does not Adversely Affect Patient Outcomes
Adnan I. Qureshi MD, Muhammad A. Saleem MD, Muhammad Shah Miran MD, Ahmed A. Malik MD
Zeenat Qureshi Stroke Institute St. Cloud MN.
Independent functional status defined by a modified Rankin scale score (mRS) of 2 or less at 90 days. All modified Rankin scale assessments at 90 (±14) days were performed by study investigators who were not involved in the treatment of the patient and who were blinded to the treatment assignment.
The angiographic procedure had to begin within 5 hours and be completed within 7 hours after symptom onset. Patients who had no angiographic evidence of a treatable occlusion received no additional treatment, and those with a treatable vascular occlusion received endovascular treatment according to principles of the protocol. The primary focus for this analysis was the group of patients who were randomized to endovascular treatment but did not receive any treatment because of absence of treatable occlusion (non-therapeutic angiogram).
Outcomes analyzed:
The following outcomes were analyzed:
Symptomatic intracranial hemorrhage was defined as an intracranial hemorrhage temporally related to a decline in neurological status and new or worsening neurologic symptoms in the judgment of the clinical investigator and which may warrant medical intervention. CT scan were performed at baseline, at 24 (±6) hours, and if there was a neurologic decline.
Neurological deterioration defined by a 4 or more point increase in the NIHSS score from baseline to subsequent CT scan at the time of potential worsening. The NIHSS assessments were performed immediately prior to initiation of intravenous rt-PA, at 24 (±6) hours, and at 5 (±1 day) or discharge from hospital.
Acute kidney injury defined by an increase in serum creatinine value at 5 (±1 day) or discharge from hospital compared with baseline creatinine value using Acute Kidney Injury Network classification. The grades were: stage 1, ≥0.3 mg/dl (≥ 26.4 umol/L) or ≥ 150% to 200%; stage 2: >200% to 300% (>2 to 3 fold); and stage 3, >300% (>3 folds).
BACKGROUND
There are concerns regarding risks of unnecessary angiograms (non therapeutic angiogram that does not lead to therapeutic intervention) in acute ischemic stroke patients who are considered for endovascular treatment.
RESULTS
METHODS
A total of 89 subjects (mean age 67.02 ±11.24; 48 were men) underwent a non-therapeutic angiogram after being randomized to endovascular treatment.
Compared with subjects who did not undergo any angiogram (n=222), subjects who underwent a non-therapeutic angiogram had similar rates of neurological deterioration within 24 hrs [OR 1.25; 95% CI 0.65–2.43] and symptomatic ICH [OR 2.70; 95% CI ].
After adjusting for potential confounders age and baseline NIHSS score strata (0-9, & 20 or greater):
(1) Rate of death at 3 months was higher among the patients who did not receive an angiogram (OR 3.81; 95% CI )
(2) Functional independence at 90 days (mRS 0-2) was not lower in individuals who received a non-therapeutic angiogram (OR 2.44; 95% CI ).
We analyzed data from Interventional Management of Stroke (IMS) III that randomly assigned eligible patients who had received intravenous rt-PA within 3 hours after symptom onset to receive additional endovascular therapy or intravenous t-PA alone, in a 2:1 ratio The trial enrolled patients aged years of age with acute ischemic stroke with a moderate-to-severe neurologic deficit (defined as an National Institutes of Health Stroke Scale [NIHSS] score ≥10 or, and in later part of the trial those with a score of 8 to 9 with CT angiographic evidence of an occlusion of the proximal middle cerebral artery, internal carotid artery, or basilar artery. dose. Patients who were randomized to endovascular treatment underwent angiography as soon as possible either at the hospital that initiated treatment with intravenous rt-PA or at another participating hospital. Intravenous rt-PA was discontinued at 40 minutes in those randomized to endovascular treatment and femoral access could occur during or after completion of the intravenous rt-PA.
CONCLUSION
Non therapeutic angiograms in acute ischemic stroke patients who are being considered for endovascular treatment does not adversely affect patient outcomes.
Table . Unadjusted and adjusted rates of outcomes
Patients with non-therapeutic angiogram
(N=89)
Patients who received intravenous rt-PA alone
(N=222)
Unadjusted Odds Ratio
OR; 95% CI
Adjusted Odds Ratio
Adjusted for Age & Baseline NIHSS strata
Functional independence at 90 days (mRS 0-2) – n(%)
56 (62.9)
90 (40.5)
2.84;
2.44;
Symptomatic intracranial hemorrhage - n(%)
2 (2.2)
13 (5.9)
2.70;
2.95;
Neurological deterioration within 24 hours - n(%)
14 (15.7)
42 (18.9)
1.25;
1.14;
Acute kidney injury- n(%)
1 (1.1)
3(1.3)
1.20;
1.60;
Deaths in 90 days - n(%)
6 (6.7)
48 (21.6)
3.81;
3.81;