The Efficacy Of Endovascular Therapy And Hypothermia Protection In Acute Ischemic Stroke With Large Infarction Core

Part 1:The efficacy of endovascular therapy for acute ischemic stroke with large infarct core.Objective : To investigate the effect and influencing factors of endovascular therapy(EVT)in patients with large infarct core and large vessel occlusive acute ischemic stroke(AIS-LVO).Methods :Consecutive cases with AIS-LVO which has a large ischemic core treated with mechanical thrombectomy in Changhai Hospital from Feb.2017 to Jun.2019 were enrolled.According to the EVT postoperative 90 days modified Rankin scale(m RS)score,the patients were divided into the good outcome(m RS score ≤2)and poor outcome group(m RS score > 2),,then analysed the preoperative baseline data,intraoperative and postoperative status of patients in the two groups to evaluate the efficacy and prognostic factors of EVT in AIS-LVO with large infarct core.Results :Totally 47 patients with infarct core volume ≥70 m L and 60 patients with Alberta Stroke Program Early CT Score(ASPECTS)< 6 were included.After the operation,93.62%(44/47)of the patients with infarct core volume ≥70 m L achieved successful recanalization,27.66%(13/47)of the patients achieved good outcome at 90 days after the operation.The rate of Intracranial hemorrhage(ICH)was 38.30%(18/47),and 10.64%(5/47)of patients occurred symptomatic intracranial hemorrhage(s ICH).The90 days mortality was 29.79%(14/47).Compared with patients with poor outcome group,group of patients with good outcome had younger age(P=0.007).Among patients with an ASPECT score < 6,93.62%(44/47)of the patients with infarct core volume ≥70 m L achieved successful recanalization,40%(24/60)of the patients achieved good outcome at90 days after the operation.The rate of Intracranial hemorrhage(ICH)was 51.67%(31/60),and 15%(9/60)of patients occurred s ICH.The 90 days mortality was20%(12/60).Conclusions:EVT can help a part of patients with AIS-LVO and large core infarction achieve good outcome.Age was the most important factor of 90-day prognosis.Part 2:Correlation of clinical prognosis and infarct core volume based on computed tomography perfusion analysis in acute ischemic stroke with large vessel occlusionObjective: To explore the correlation of clinical outcome with preoperative infarct core volume and to analyze the predicting factors affecting clinical outcome in patients with large infarct core volume.Methods: Retrospectively analyze patients with acute ischemic stroke and large vessel occlusion who received thrombectomy within 6 hours after they were last known to be well in Changhai Hospital from Jun.2017 to Dec.2018 were enrolled..Patient’s demographics and comorbidities,imaging features,treatment processes,and outcomes were analyzed.The influence of infarct volume on the clinical outcome was analyzed by univariate and multivariate analysis.The receiver operating characteristic curve was plotted with the infarct core volume and clinical outcome.Results: A total of 189 patients were enrolled.Good outcome was achieved in 83(43.92%)patients at 90 days.Age,baseline National Institutes of Health Stroke Scale(NIHSS)score,preoperative infarct core volume,and intracranial hemorrhage were the risk factors for poor outcome.The cut-off value of infarct core volume determined by the receiver operating characteristic curve was 61 ml and the area under the receiver operating characteristic curve was 0.710.In patients with large infarct core volume(>61ml),poor outcome was associated with female gender(P=0.038),and longer time from groin puncture to revascularization(P=0.033).Conclusions: For acute ischemic stroke patients with anterior circulation large vessel occlusion within 6 hours,the preoperative infarct core volume is a risk factor for poor outcome.Patients with a infarct core volume≤61 ml received significantly better outcomes.Part III: Safety and feasibility of hypothermia protection in acute ischemic stroke with large infarction coreObjective: To investigate the safety and feasibility of therapeutic hypothermia(TH)in AIS-LVO patients with large infarct core volume by using extracorporeal circulation to cool the blood outside the body and then transfused through the hypothermia catheter combined with EVT.Methods: According to inclusive and exclusive criteria,6-12 AIS-LVO patients with large infarct core who received EVT and achieved reperfusion successfully(m TICI≥2b)in the stroke center of Changhai Hospital were prospectively enrolled using the “3+3”stepped-wedge design.The hypothermia was performed by using extracorporeal circulation to cool the blood outside the body and then transfused through the hypothermia catheter.Results: A total of 6 patients were included,all patients completed the predetermined procedure.Among them,there were 3 males and 3 females,aged 39-75 years,4 patients had atrial fibrillation,NHISS score was 18-35,ASPECTS was 3-8,and infarction core volume was 81-181 m L,and 5 of them were left hemisphere infarction.The time from onset to puncture was 126-449 minutes in,and 1 patient achieved a good outcome at 90 days(m RS 0-2).One of the patients received hemicraniectomy 24 hours later after the hypothermia treatment due to large infarction core.The shortest time to reach target temperature is 10 minutes.The maximum time of performing extracorporeal circulation was 16 hours.The temperature of cerebral tissue was decreased to 28.5℃,and the minimum systemic temperature was 33.8℃.Conclusions: Hypothermia is safe and feasible for AIS-LVO patients with large infarction core volume,and moderate hypothermia(28-32 ℃)is also clinically safe for AIS-LVO patients.