Publication: Farklı Etyolojik Alt Tiplerde Akut İskemik İnme Tedavisinin Sonuçları
Abstract
Giriş ve amaç: Dünya sağlık örgütüne göre inme klasik olarak, 'vasküler nedenler dışında açıklayıcı başka neden olmaksızın santral sinir sisteminde meydana gelen akut fokal hasar ve buna bağlı gelişen nörolojik defisit' olarak tanımlanmıştır (1, 2). Bütün inmelerin yaklaşık %80'i iskemik inmedir. İnme dünya genelinde ikinci ölüm nedeni iken erişkin çağda en sıkengellilik nedenidir. İnsidans, prevelans ve mortalite açısından ülkeler arasında farklılıklar bulunmaktadır. Bunun en önemli nedeni risk faktörleri profilindeki değişikliklerdir. Akut iskemik inmede tıkanma yerine ve vasküler kollateral durumuna göre değişen büyüklükte hücre ölümü meydana gelmektedir. Akut dönemde işlevlerini yitiren ancak canlılığını henüz kaybetmemiş hücreler (penumbra) bulunmaktadır. Akut iskemik inme tedavisinde hücresel düzeyde nörolojik hasarın ve fonksiyonel kaybın en aza indirilebilmesi için penumbrayı kurtarabilmek hedeflenmektedir (1-2). 1995 yılında Birleşik Devletlerde yapılan çok merkezli NINDS (National Institute of Neurological Disorders and Stroke intravenous tissue plasminogen activator (t-PA) in acute stroke treatment) çalışması ile 2009 yılında Avrupa kökenli ECASS-III çalışması ile IV-tPA'nın 3 ile 4.5 saatler arasında da uygulandığında klinik fayda sağlayacağı ortaya konmuştur (3-4). Bu çalışmalar sonucunda AHA/ANA (American Heart Academy/American Neurology Acedemy) klavuzları güncellenerek 'Akut İnme tedavisi' günümüzde tüm akut iskemik inme hastalarında kontrendikasyon yoksa ilk 4,5 saat içerisinde IV-tPA uygulaması Sınıf 1A öneri olarak yerini almıştır (4). Gösterilmiş etkinliğine karşın IV-tPA'nın uygulama penceresinin dar olması, sistemik/intrakranial hemoraji riski ve trombüs yükü ile ilişkili proksimal büyük damar oklüzyonu olan hastalarda düşük yanıt oranı alternatif tedavi seçeneklerinin gündeme gelmesine yol açmıştır (2). 2014 yılında Hollanda'da gerçekleştirilen MR-CLEAN çalışması ile ilk 6 saatte intraarteriyel fibrinolitik uygulaması ya da özel stent veya cihazlarla serebral damarı tıkayan pıhtının eritilerek rekanalizasyonun sağlanması ile klinik takiplerde hastalarda nörolojik ve fonksiyonel anlamlı iyileşme elde edildiği kanıtlanmıştır (5). Yaygın olarak hem ülkemizde hem de dünyada kullanıma giren sistemik ve endovasküler tedavilerin iskemik inmenin farklı etyoloijk alt tiplerinde ne kadar etkili oduğu konusu ise pek araştırılmamış belirsiz bir konudur. Çalışmamızda farklı etyolojik alt tiplerde akut iskemik inme tedavisinin sonuçları değerlendirilmiştir. İskemik inme alt tiplerinin sınıflanmasının temel amacı etyolojik olarak serebral enfarktüsün nedeninin saptanması ve sekonder proflaksinin planlanmasıdır Etyolojik alt tip belirlendiğinde, akut inme tedavisi, sekonder proflaksi yöntemi ve prognoz farklılaşacaktır. Literatür incelendiğinde farklı iskemik inme alt tiplerinin akut iskemik inme tedavisindeki rekanalizasyon üzerine etkilerini inceleyen çalışmalar sınırlıdır. Çalışmamızda iskemik inmenin etyolojik alt tipi ile akut iskemik inmede intravenöz/intrarteriyel trombolilitik tedavi ve endovasküler tedavisonrası erken ve geç dönem klinik iyileşme arasındaki ilişkinin araştırılması hedeflenmiştir. Hastalar ve yöntem: Çalışmaya Mart 2004-Mart 2021 tarihleri arasında Ondokuz Mayıs Üniversitesi Tıp Fakültesi Nöroloji Kliniği'nde akut iskemik inme tanısı ile IV-tPA, endovasküler tedaviya da intraarteriyel fibrinolitik uygulanan 18 yaş üstündeki hastalar dahil edildi. Hastane kayıtları, OMÜ Tıp Fakültesi Beyin Damar Hastalıkları polikliniği veri tabanındaki 2668 hasta ve anjiyografi ünitesinde yapılan işlem kayıtlarındaki 5000 hasta geriye dönük olarak incelendi. 249 hastaya akut iskemik inme tedavisi verildiği görüldü. İncelemeler sonucunda IV-tPA verilen 158, endo vasküler tedavi uygulanan 38, toplam 196 hasta ile analizler tamamlandı. Çalışmamız lokal etik komite tarafından onaylandı. İskemik inmenin etyolojik alt tipinin belirlenmesi için CCS (CausativeClassification of Stroke) sistemi kullanıldı. Yapılan değerlendirmeler sonucunda hastalar 5 alt tipe ayrıldı; büyük damar aterosklerozuna bağlı inme, kardiyoembolik inme, laküner enfarktlar, inmenin diğer nadir nedenleri ve nedeni belirlenemeyen grup. İstatiksel analizlerde ise kriptojenik inme grubu ve ESUS hastaları diğer inme nedenleri arasına dahil edildi. Etyolojik inme alt tipini belirlemek için gerekli incelemeler tamamlanamayan hastalar analizlere dahil edilmedi. Hastaların yaş ve cinsiyet gibi demografik özellikleri, başvuru sırasındaki nörolojik muayene ve NIHSS skorları, atrial fibrilasyon, hipertansiyon, hiperlipidemi, diyabetes mellitus, sigara kullanımı, aterosklerotik kalp hastalığı gibi risk faktörleri, başvuru esnasında glukoz, ortalama kan basıncı değerleri, semptom başlangıcı ile IV-tPA başlanma süresi (Semptom iğne zamanı) ve endovasküler işleme başlama süresi (semptom-kasık zamanı) kaydedildi. Çalışmanın birincil sonlanım noktası olarak 1, 7 ve 90.günlerde NIHSS skorlarındaki düzelme, ikincil sonlanım noktası olarak da 3aydaki mortalite, mRS ve Barthel İndeksi (Bİ) alındı. Nöroloijk düzelmenin gösterilmesi için 24.saat, 7.gün, 90. gün sonunda tespit edilen NIHSS, başvuru anındaki skorlarla karşılaştırıldı. NIHSS skorunda 8ve üzerinde azalma, mRS skoru 0-1 olanlar ile 0-1-2 olanlar 'iyi nörolojik düzelme' olarak belirlendi. Günlük yaşam kalitesini ve bağımlılık düzeyini değerlendirmek için 3.ay Bİ'i kullanıldı. Barthel İndeksi 60 puan ve üzerinde olan hastalar 'kısmi ve/veya bağımsız hasta' olarak değerlendirmeye alındı. 90 gün içerisindeki tüm ölümler diğer sonlanım noktasıydı. Endovasküler tedavi uygulanan hastalarda rekanalizasyon düzeyi işlem sırasında çekilen kontrol anjiyografilerde TICI skalası ile belirlendi. TICI 2b ve 3 düzeyinde rekanlizasyon başarılı endovasküler tedavi olarak kabul edildi. Sistemik veya endovasküler tedaviden sonra görülen komplikasyonlar sistemik veya intrakranial kanama olarak ayrıldı. İntrakranial hemoraji sınıflaması 'hemorajik enfarkt tip I ve tip II' ile 'parankimal hematom tip I ve tip II' olarak ayrıldı. Ölüme yol açan kanama terimi, kanama komplikasyonu geliştikten sonra ilk 72 saatte gerçekleşen ölümler için kullanıldı. Bulgular: Çalışmamızda akut iskemik inme tedavisi alan 196 hastanın ortalama yaşı 64,57 idi. Hastaların 108'i erkek (%55,10), 88'i kadındı (%44,90). İnme şiddeti 101 hastada orta (%51,53), 62 hastada ağır (%31,63), 33 hastada (%16,83) şiddetliydi. Başvuu anındaki ortalam kan basıncı 78,21, kan şekeri ise 156,36 idi. Ortalama semptom kapı süresi 99,6 dakika, IV-tPA verilen grupta ortalama kapı-iğne zamanı 64,16 dk, endovasküler tedavi alan grupta ortalama kapı-kasık zamanı 105,63 dakikaydı. İnme alt tipinin 1, 7 ve 90. günlerdeki NIHSS skorlarındaki iyileşme üzerine etkisi yoktu. Büyük damar aterosklerozuna bağlı inme hastalarında 1 ve 7. gün NIHSS skorlarında 8 puan ve üzerinde düzelme olan hasta oranı istatistiksel olarak anlamlılığa ulaşmasa da en fazlaydı (p>0.05).1.7 ve 90. gün NIHSS skorlarında en fazla düzelme büyük damar aterosklerozuna bağlı grupta gözlendi. Tek değişkenli analizlerde inme alt grupları arasında 3. ay mRS, Bİ skorları ve mortalite açısından anlamlı fark saptandı (p<0.05). Kardiyoembolik inme alt tipi kötü fonksiyonel sonuçlar ile ilişkili bulundu. 3.ay sonunda mortalite oranlarının en yüksek olduğu grup yine kardiyoembolik inme grubu idi (p<0.05). Ancak diğer faktörlerle birlikte çok değişkenli analize koyulduğunda inme alt tipinin ikincil sonlanım noktaları üzerine anlamlı etkisi kayboluyordu (p>0.05). Kardiyoembolik hastaların %67,27 'sinde AF varlığı ve AF'si olan hastaların ise %31,75'i mortalite vardı. Ölen hastalar arasında en büyük grubu kardiyoembolik inmeler oluşturuyordu (p<0.05, OR=0,393 [CI: %95, 0,094-1,643]). Değerlendirilen diğer parametreler arasında çok değişkenli analizler sonucunda IV-tPA alan grupta baş vuru kan şekerinin 180 mg/dl üzerinde olmasının 7 ve 90.gün NIHSS skorlarındaki iyileşme ve mortalite üzerine olumsuz etki gösterdiği ortaya çıktı (p<0.05). Ortalama başvuru kan basıncının 110 mmHg üzerinde olması mortalite ile, AF varlığı da 3. ay mRS skorları ile istatiksel olarak anlamlı derecede ilişkili bulundu (p<0.05). Çalışmamızda IV-tPA tedavisi alan hasta grubunda sigara kullanıyor olmanın 3 aylık fonkisyonel bağımsızlık üzerine olumlu etkisi olduğu bulundu (p<0.05, OR=0,353 [CI: %95, 0,125-0,997]). Endovasküler tedavi uygulanan 38 hastada inme alt gruplarının rrekanlizasyon oranları ve klinik iyileşme üzerine bir etkisi olmadığı görüldü (p>0.05). Çok değişkenli analizlerde 3. ay mRS ve Barthel İndeksi üzerine etkili olan tek parametre AF varlığı ve başvuru kan şekerinin 180 mg/dl'den fazla olmasıydı (p<0.05). Sonuç: Çalışmamız sonucunda tüm inme alt tipleri değerlendirldiğinde rekanalizasyon oranlarının en düşük olduğu, nörolojik iyileşmenin ve fonksiyonel bağımsızlığın en kötü sonuçlandığı inme alt tipi kardiyoembolik inme alt tipi olduğu bulunmuştur. Ancak tüm bulgular birlikte değerlendirildiğinde inme alt tiplerinin tümünde akut iskemik inme tedavisinin benzer derecede etkin olduğu ve zaman aralığına uyan ve kontrendikasyon olmayan tüm hastaların hangi inme alt tipinde olursa olsun IV-tPA almaları veya endovasküler tedaviuygulanması gerektiği sonucuna varılmıştır.
Introduction and Objectives: Stroke is described as acute onset focal or global neurological dysfunction and deficit due to vascular reasons by World Health Organisation (1, 2). 80-85% of all strokes are ischemic. Stroke is the second most common cause of mortality and the most common cause of morbidity in all over the world. The incidence, prevalence and mortality rates may differ among countries. The most important reason for this is differences of risk factor profiles. The level of neuronal loss is determined by the occlusion site and collateral status. Penumbra defines the neurons which are unable to function, however still alive. The main target of acute ischemic stroke treatment is to save penumbral neurons to minimise the neurologic injury and functional loss at the cellular level. Two multicenter controlled prospective trials, NINDS in 1995, and ECASS-III in 2009, revealed intravenous tissue type plasminogen activator (IV-tPA) supply significant clinical improvement in acute ischemic stroke patients, if given within 3 to 4.5 hours (3-4). The most recent guidelines like ESO and AHA/ANA recommends IV-tPA for acute ischemic stroke patients within first 4.5 hours if there is no contraindication with Class IA evidence (4). Besides this proven efficacy, the narrow treatment window of IV-tPA, systemic and intracranial risk of haemorrhage, low response in the cases of proximal large vessel occlusion with large thrombus load lead to development of new and more effective solutions (2). MR-CLEAN study revealed that specific retrievable stents, together with tPA or not, may supply recanalisation of cerebral vessels occluded with clots, and cause significant neurological and functional improvement (5). For today, the efficacy of systemic or endovascular treatment options in different ischemic stroke subtypes is still an unclear and uninvestigated era. In the present study, we evaluated the clinical results of these two treatments in different stroke subtypes. The basic scope of determining etiologic subtype of ischemic stroke is for demonstrating the reason of cerebral vessel occlusion and make decision about the secondary prophylaxis alternatives. When the subtype is defined, the details of acute treatment, the way for prevention of a recurrent stroke and the prognosis will differ. The research for the effects of different ischemic stroke subtypes on recanalisation and clinical outcomes is lacking in the most recent literature. In this study we aimed to determine the correlation between different ischemic stroke subtypes and short and long term clinical and functional recovery after intravenous/intra-arterial thrombolytic treatment and mechanical thrombectomy. Patients and Method: Patients over 18 years who received intravenous or intra-arterial tPA and mechanical thrombectomy for the diagnosis of acute ischemic stroke between March 2004 and March 2021 are included in the study. 2668 patients from the hospital records and Cerebrovascular Diseases Outpatient Clinic data base and 5000 patients from the angiography unit records are searched retrospectively. There were 249 patients who received systemic or endovascular acute ischemic stroke treatment. The final analysis is performed with 158 patients who received IV-tPA and 38 patients who was treated with endovascular procedure. The study is approved by the local ethics committee. The etiologic subtype of ischemic stroke is determined according to CCS (Causative Classification of Stroke) system. Five subgroups are defined, large artery atherosclerosis, cardio-aortic embolism, small artery occlusion, other causes and undetermined group. The cryptogenic group and ESUS patient are included in the other rare causes of ischemic stroke group. Patients whose investigations to define the subtype were not completed, are excluded from the analysis. Demographic features like age and gender, admittance neurological examination and NIHSS scores, risk factors like presence of atrial fibrillation, hypertension, diabetes, atherosclerotic heart disease, and smoking, admittance blood pressure and blood glucose level, symptom-needle time for IV-tPA patients, onset-puncture time for mechanical thrombectomy patients are recorded for all. The primary endpoint of our study was improvement of the NIHSS scores at day 1, 7 and 90. The secondary end points of the study were mRS, Barthel Index and mortality at the end of third month. For decision of good recovery, the decrease in NIHSS scores at the 1st, 7th and 90th days according to the pre-treatment scores is calculated. Modified Rankin scores of 0, 1 and 2 at the end of three months are also accepted as good recovery. Functional recovery and daily life performance is evaluated by BI. Patients with Barthel Index scores over 60 at the end of three months are supposed to have functional independence. The level of recanalisation after endovascular treatment is defined according to TICI scale. Recanalisation at TICI 2b and 3 levels are accepted to have successful recanalisation. The complications of systemic or endovascular treatment are divided into two groups as systemic and intracranial haemorrhages. Intracranial haemorrhages are defined as 'hemorrhagic infarction type I and type II' and paranchymal hematoma type I and type II. Haemorrhage leading to the death is defined for patient lost at most 72 hours after haemorrhage. Results: The mean of 196 patients who received acute stroke treatment was 65,57. 108 of the patients were male (%55,10), 88 of the patients were women (%44.90). Stroke severity was moderate in 101 (%51,53), moderate to severe in 62 (%313.63), and severe in 33 patients (%16.83). Mean admittance blood pressure was 78,21, mean admittance blood sugar was 156,36. Mean symptom to door time was 99,6 minutes, mean door to needle time was 64,16 minutes for IV-tPA patients, and mean door to puncture time was 105,63 minutes for endovascular treatment group. The ischemic stroke subtype showed no significant correlation with the improvement of NIHSS scores at the 1st, 7th and 90th days. The rates of patients with 8 or more points improvement in NIHSS scores after one and seven days were highest in the large artery atherosclerosis group however the difference was not significant (p>0.05). The highest decrease of NIHSS score in the 1st, 7th and 90th days was observed in large arterial atherosclerosis group. Univariate analysis revealed a significant difference among stroke subtypes in the aspects of 3rd month mRS Barthel Index and mortality (p<0.05). Cardioembolic stroke is found to have worst functional outcome. The mortality rate was again highest in the cardioembolic group (p<0.05). However, the significant effect of stroke subtype over functional recovery and mortality at the 3rd month is lost after adjustment with other parameters (p>0.05). 67,27% of cardioembolic patients had atrial fibrillation, 31,75% of atrial fibrillation patients deceased. The mortality rate was significantly higher in patients with atrial fibrillation (p<0.05, OR=0,393 [CI: %95, 0,094-1,643]). After the multivariate analysis of all parameters, levels of admittance blood sugar over 180 mg/dl is found to be inversely correlated with recovery of NIHSS scores at 7th and 90th days and 3 months mortality (p<0.05) Mean admittance blood pressure over 110 mmHg is correlated with 3 months mortality, presence of atrial fibrillation is correlated significantly with 3 months mRS scores (p<0.05). Our study also revealed a significantly positive effect of smoking on the functional independence after three months (p<0.05, OR=0,353 [CI: %95, 0,125-0,997]). Ischemic stroke subtype had no significant effect over neither revascularisation rates nor clinical recovery in 38 patients received endovascular treatment (p>0.05). After adjustment, the novel parameters correlated significantly with 3 months mRS score and Barthel Index were presence of atrial fibrillation and admittance blood sugar level over 180 mg/dl, in the endovascular treatment group (p<0.05). Conclusion: The results of our study revealed that cardioembolic stroke is the ischemic stroke subtype which has the worst neurological recovery and functional recovery and the lowest rate of recanalisation. However, after adjusting for all of the parameters investigated, systemic thrombolysis and endovascular treatment is effective smilarly in all of the ischemic stroke etiologic subtypes. All ischemic stroke patients who admitted in the appreciate time window should be considered for IV-tPA or mechanical thrombectomy, if there is no contraindication, regardless of etiologic subtype.
Introduction and Objectives: Stroke is described as acute onset focal or global neurological dysfunction and deficit due to vascular reasons by World Health Organisation (1, 2). 80-85% of all strokes are ischemic. Stroke is the second most common cause of mortality and the most common cause of morbidity in all over the world. The incidence, prevalence and mortality rates may differ among countries. The most important reason for this is differences of risk factor profiles. The level of neuronal loss is determined by the occlusion site and collateral status. Penumbra defines the neurons which are unable to function, however still alive. The main target of acute ischemic stroke treatment is to save penumbral neurons to minimise the neurologic injury and functional loss at the cellular level. Two multicenter controlled prospective trials, NINDS in 1995, and ECASS-III in 2009, revealed intravenous tissue type plasminogen activator (IV-tPA) supply significant clinical improvement in acute ischemic stroke patients, if given within 3 to 4.5 hours (3-4). The most recent guidelines like ESO and AHA/ANA recommends IV-tPA for acute ischemic stroke patients within first 4.5 hours if there is no contraindication with Class IA evidence (4). Besides this proven efficacy, the narrow treatment window of IV-tPA, systemic and intracranial risk of haemorrhage, low response in the cases of proximal large vessel occlusion with large thrombus load lead to development of new and more effective solutions (2). MR-CLEAN study revealed that specific retrievable stents, together with tPA or not, may supply recanalisation of cerebral vessels occluded with clots, and cause significant neurological and functional improvement (5). For today, the efficacy of systemic or endovascular treatment options in different ischemic stroke subtypes is still an unclear and uninvestigated era. In the present study, we evaluated the clinical results of these two treatments in different stroke subtypes. The basic scope of determining etiologic subtype of ischemic stroke is for demonstrating the reason of cerebral vessel occlusion and make decision about the secondary prophylaxis alternatives. When the subtype is defined, the details of acute treatment, the way for prevention of a recurrent stroke and the prognosis will differ. The research for the effects of different ischemic stroke subtypes on recanalisation and clinical outcomes is lacking in the most recent literature. In this study we aimed to determine the correlation between different ischemic stroke subtypes and short and long term clinical and functional recovery after intravenous/intra-arterial thrombolytic treatment and mechanical thrombectomy. Patients and Method: Patients over 18 years who received intravenous or intra-arterial tPA and mechanical thrombectomy for the diagnosis of acute ischemic stroke between March 2004 and March 2021 are included in the study. 2668 patients from the hospital records and Cerebrovascular Diseases Outpatient Clinic data base and 5000 patients from the angiography unit records are searched retrospectively. There were 249 patients who received systemic or endovascular acute ischemic stroke treatment. The final analysis is performed with 158 patients who received IV-tPA and 38 patients who was treated with endovascular procedure. The study is approved by the local ethics committee. The etiologic subtype of ischemic stroke is determined according to CCS (Causative Classification of Stroke) system. Five subgroups are defined, large artery atherosclerosis, cardio-aortic embolism, small artery occlusion, other causes and undetermined group. The cryptogenic group and ESUS patient are included in the other rare causes of ischemic stroke group. Patients whose investigations to define the subtype were not completed, are excluded from the analysis. Demographic features like age and gender, admittance neurological examination and NIHSS scores, risk factors like presence of atrial fibrillation, hypertension, diabetes, atherosclerotic heart disease, and smoking, admittance blood pressure and blood glucose level, symptom-needle time for IV-tPA patients, onset-puncture time for mechanical thrombectomy patients are recorded for all. The primary endpoint of our study was improvement of the NIHSS scores at day 1, 7 and 90. The secondary end points of the study were mRS, Barthel Index and mortality at the end of third month. For decision of good recovery, the decrease in NIHSS scores at the 1st, 7th and 90th days according to the pre-treatment scores is calculated. Modified Rankin scores of 0, 1 and 2 at the end of three months are also accepted as good recovery. Functional recovery and daily life performance is evaluated by BI. Patients with Barthel Index scores over 60 at the end of three months are supposed to have functional independence. The level of recanalisation after endovascular treatment is defined according to TICI scale. Recanalisation at TICI 2b and 3 levels are accepted to have successful recanalisation. The complications of systemic or endovascular treatment are divided into two groups as systemic and intracranial haemorrhages. Intracranial haemorrhages are defined as 'hemorrhagic infarction type I and type II' and paranchymal hematoma type I and type II. Haemorrhage leading to the death is defined for patient lost at most 72 hours after haemorrhage. Results: The mean of 196 patients who received acute stroke treatment was 65,57. 108 of the patients were male (%55,10), 88 of the patients were women (%44.90). Stroke severity was moderate in 101 (%51,53), moderate to severe in 62 (%313.63), and severe in 33 patients (%16.83). Mean admittance blood pressure was 78,21, mean admittance blood sugar was 156,36. Mean symptom to door time was 99,6 minutes, mean door to needle time was 64,16 minutes for IV-tPA patients, and mean door to puncture time was 105,63 minutes for endovascular treatment group. The ischemic stroke subtype showed no significant correlation with the improvement of NIHSS scores at the 1st, 7th and 90th days. The rates of patients with 8 or more points improvement in NIHSS scores after one and seven days were highest in the large artery atherosclerosis group however the difference was not significant (p>0.05). The highest decrease of NIHSS score in the 1st, 7th and 90th days was observed in large arterial atherosclerosis group. Univariate analysis revealed a significant difference among stroke subtypes in the aspects of 3rd month mRS Barthel Index and mortality (p<0.05). Cardioembolic stroke is found to have worst functional outcome. The mortality rate was again highest in the cardioembolic group (p<0.05). However, the significant effect of stroke subtype over functional recovery and mortality at the 3rd month is lost after adjustment with other parameters (p>0.05). 67,27% of cardioembolic patients had atrial fibrillation, 31,75% of atrial fibrillation patients deceased. The mortality rate was significantly higher in patients with atrial fibrillation (p<0.05, OR=0,393 [CI: %95, 0,094-1,643]). After the multivariate analysis of all parameters, levels of admittance blood sugar over 180 mg/dl is found to be inversely correlated with recovery of NIHSS scores at 7th and 90th days and 3 months mortality (p<0.05) Mean admittance blood pressure over 110 mmHg is correlated with 3 months mortality, presence of atrial fibrillation is correlated significantly with 3 months mRS scores (p<0.05). Our study also revealed a significantly positive effect of smoking on the functional independence after three months (p<0.05, OR=0,353 [CI: %95, 0,125-0,997]). Ischemic stroke subtype had no significant effect over neither revascularisation rates nor clinical recovery in 38 patients received endovascular treatment (p>0.05). After adjustment, the novel parameters correlated significantly with 3 months mRS score and Barthel Index were presence of atrial fibrillation and admittance blood sugar level over 180 mg/dl, in the endovascular treatment group (p<0.05). Conclusion: The results of our study revealed that cardioembolic stroke is the ischemic stroke subtype which has the worst neurological recovery and functional recovery and the lowest rate of recanalisation. However, after adjusting for all of the parameters investigated, systemic thrombolysis and endovascular treatment is effective smilarly in all of the ischemic stroke etiologic subtypes. All ischemic stroke patients who admitted in the appreciate time window should be considered for IV-tPA or mechanical thrombectomy, if there is no contraindication, regardless of etiologic subtype.
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