Review some factors related to neurological functional recovery outcome in the treatment of acute ischemic stroke by the solitaire device

Nội dung text: Review some factors related to neurological functional recovery outcome in the treatment of acute ischemic stroke by the solitaire device

1. Journal of military phrmaco-medicine n O7-2017 REVIEW 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 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 The circulating blood volume is severely reduced, the function of area of the brain Stroke is a common disease in the is disordered [1]. A cerebral infarction can world as well as Vietnam. It is the third occur for a few minutes as the circulating most common cause of death after heart blood volume is reduced so it is rapid disease and cancer and is the single reason revascularization and restoration of for permenant disability. More than 700,000 circulation. new strokes occur each year in the United States alone, accounting for more than In 1996, Food and Drug Administration 45 billion dollars in medical expenses, (FDA) approved the administration of rehabilitation costs, and loss of employment intravenous (IV) recombinant tissue [3]. plasminogen activator (rt-PA) within Stroke is a pathological process. Therein, 3 hours of symptoms onset for the treatment the cerebral artery is narrowed or occluded. 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 121
2. Journal of military parmaco-medicine n 07-2017 Due to the time limitation and contraindications device to restore blood flow. Patients had a to intravenous tissue-type plasminogen intracranial and terminus internal carotid activator (IV tPA), < 10% of patients with artery (ICA), first and second segments stroke receive the treatment, even in well- of the middle cerebral artery (MCA), organized stroke networks. Furthermore, basilar artery (BA) and first segment IV tPA recanalizes only 40% of large vessel posterior cerebral artery (PCA), patients occlusions in patients with acute stroke were refractory to intrarvenous IV tPA or during the first hours after administration the patient had contraindications for with even lower rates of revascularization systemic thrombolysis within 6 hours from for proximal arterial occlusions such as onset stroke symptoms. the terminal internal carotid artery. Thus, * Inclusion criteria: faster and more effective approaches to - No hemorrhage image on CT-scanner reperfusion are needed [4]. Clinical results or MRI. have shown that mechanical devices for clot removal provide an alternative treatment - From the onset of stroke symptoms option to patients with stroke who are to treatment ≤ 6 hours. ineligible for thrombolytic therapy. The - Patients have proximal vessel large solitaire device has received US Food arterial occlusion: Intracranial and terminus and Drug Administration clearance for use internal carotid artery (ICA), first and in the revascularization of patients with acute second segments of the middle cerebral ischemic stroke secondary to intracranial artery (MCA), basilar artery (BA) and first large vessel occlusive disease. In Vietnam, segment posterior cerebral artery (PCA). this approach has been deployed in some - Patients visit the hospital > 4.5 hours hospitals and received good results. after the onset of stroke symptoms or Therefore, we have studied this topic ineligibility for or failure to respond to to aim: Review some factors related to intravenous rt-PA. neurological functional recovery outcome - Patients and their families agree to in the treatment of acute ischemic stroke treat. by the solitaire device. * Exclusion criteria: - The exact time of onset stroke symptoms SUBJECTS AND METHODS is unknown. 1. Subjects. - Systolic blood pressure ≥ 185 mmHg We conducted a prospective study to or diastolic blood pressure ≥ 110 mmHg is evaluate all consecutive patients with uncompensated. 3 ischemic stroke, who were treated from - Platelet below 100,000/mm . Hematocit April, 2014 to September, 2016 at below 25%. People ’s Hospital 115. Patients had - Blood glucose < 50 mg/dL (2.8 mmol/L) received Solitaire device as the first-choice or > 400 mg/dL (22.2 mmol/L). 122
3. Journal of military phrmaco-medicine n O7-2017 - Activated partial thromboplastin time - Ischemic infarction occurs in more than (aPTT) > 50 seconds. Anticoagulation with a third of the middle cerebral artery territory IRN (International Normal Ratio) > 3.0 or on CT-scanner. administration of heparin within the early 2. Methods. 48 hours. Prospective study and case series. RESULTS AND DISCUSSIONS 1. Age. Table 1 : Age factor related to the neurological functional revovery outcome. mRS 0 - 2 mRS 3 - 6 OR p Number Rate Number Rate 95%CI (n = 52) (%) (n = 52) (%) Age < 70 48 55.2 39 44.8 4.00 0.03 (1.2 - 13.2) ≥ 70 4 23.5 13 76.5 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. mRS 0 - 2 mRS 3 - 6 OR p TICI 95%CI Number (n = 52) Rate (%) Number (n = 52) Rate (%) 0.19 < 2 6 22.2 21 77.8 0.001 (0.07 - 0.53) ≥ 2 46 59.7 31 40.3 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. 123
4. Journal of military parmaco-medicine n 07-2017 3. 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 mRS 0 - 2 mRS 3 - 6 OR 95% CI p Number (n = 52) Rate (%) Number (n = 52) Rate (%) ≤ 15 25 69.4 11 30.6 3.45 0.007 (1.46 - 8.15) > 15 27 39.7 41 60.3 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. mRS 0 - 2 mRS 3 - 6 Symptomatic OR 95% CI p incranial hemorrhage Number Rate Number Rate (n = 52) (%) (n = 52) (%) No 52 57,1 39 42.9 0.42 > 0.05 (0.33 - 0.54) Yes 0 0.0 13 100.0 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]. 124
5. Journal of military phrmaco-medicine n O7-2017 5. Multivariate regression statistical analysis. Table 5: Multivariate regression statistical analysis of risk factors related to neurological function recovery outcome. Factors Beta coeficient p OR 95%CI < 70 Age 0.121 0.160 4.00 1.2 13.2 ≥ 70 < 2 TICI - 0.309 0.000 0.19 0.07 0.53 ≥ 2 Symptomatic incranial No 0.319 0.000 0.42 0.33 0.54 hemorrhage Yes ≤ 15 NIHSS 0.245 0.005 3.45 1.46 8.15 > 15 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 hemorrhage, severe stroke levels); no good revascularization group (TICI 0 - 2A), - Simple variable statistical analysis: symptomatic incranial hemorrhage group, + The risk factors related to good severity stroke group (NIHSS > 15) associated neurological functional outcome: the age with impaired neurological functional group less than 70, good revascularization rehabilitation (mRS 3 - 6). (TICI ≥ 2B), mid and moderate stroke (NIHSS ≤ 15). REFERENCES + The risk factors related to no good 1. Nguy ễn V ăn Ch ươ ng . Th ực hành th ần neurological functional outcome: the kinh t ập III: B ệnh h ọc th ần kinh. Nhà xu ất b ản age group greater than 70, no good Y h ọc. 2005, tr.7-73. revascularization (TICI 0 -2A), severity 2. Ph ạm Nguyên Bình . Đánh giá tính an stroke (NIHSS > 15) and symptomatic toàn và hi ệu qu ả ph ươ ng pháp l ấy huy ết kh ối incranial hemorrhage. bằng d ụng c ụ c ơ h ọc solitaire ở b ệnh nhân đột qu ỵ nh ồi máu não. Lu ận v ăn Th ạc s ỹ - Multivariate regression statistical analysis Y h ọc. Tr ường Đạ i h ọc Y D ược Thành ph ố revealed that factors related to neurological Hồ Chí Minh. 2013. functional recovery outcome are age group, 3. Perry P. Ng, Randall T. Higashida, Sean revascularization, symptomatic incranial P. Cullen et al. Intraarterial thrombolysis trials 125
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