Time-resolved assessment of collateral flow using 4D CT angiography in large-vessel occlusion stroke

Background and Purpose: We aim to evaluate if good collateral flow (CF) modifies endovascular therapy (EVT) efficacy on large-vessel stroke. To do that, we used final degree of reperfusion and number of device-passes performed, factors previously associated with better functional outcome, as main outcome measures. Methods: Single-center retrospective study including consecutive stroke patients receiving EVT for anterior circulation large-vessel stroke. CF degree was assessed on CT angiography before EVT using a previously validated 4-grade score. Final degree of reperfusion, using modified Thrombolysis in Cerebral Ischemia (mTICI), and number of device-passes performed were prospectively collected. Multivariable analysis was performed to evaluate the influence of collateral flow degree on final degree of reperfusion and number of device-passes performed. Results: Six hundred twenty-six patients were included in the study; 369 patients (59%) presented good collateral flow on CT angiography. Five hundred twenty-two patients (84%) achieved successful reperfusion (mTICI 2B-3) after EVT, 304 (48%) of them with a final mTICI 2C-3. Median number of device-passes was 2 (interquartile range, 1–3). Good CF was independently associated with better final degree of reperfusion (shift analysis for mTICI0-2A/2B/2C-3%, poor CF 19/38/43 versus good CF 15/32/53, adjusted odds ratio, 1.51 [95% CI, 1.08–2.11]). Poor CF was independently associated with higher number of device-passes performed to achieve successful reperfusion (mTICI2B-3; shift analysis for 1/2/3/4+ device-passes, adjusted odds ratio, 1.59, [95% CI, 1.09–2.31]) and complete reperfusion (mTICI2C-3; shift analysis for 1/2/3/4+ device-passes, adjusted odds ratio, 1.70 [95% CI, 1.04–2.90]). Conclusions: Patients with good CF treated with EVT experience higher rates of successful reperfusion with lower number of device-passes. CF may facilitate thrombus retrieval and prevent distal embolization of clot fragments, improving device-passes efficacy.

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Better Collaterals Are Independently Associated With Post-Thrombolysis Recanalization Before Thrombectomy

Stroke ◽

10.1161/strokeaha.118.022815 ◽

2019 ◽

Vol 50 (4) ◽

pp. 867-872 ◽

Cited By ~ 10

Author(s):

Pierre Seners ◽

Pauline Roca ◽

Laurence Legrand ◽

Guillaume Turc ◽

Jean-Philippe Cottier ◽

...

Keyword(s):

Acute Stroke ◽

Multivariable Analysis ◽

Brain Magnetic Resonance Imaging ◽

Intravenous Thrombolysis ◽

Large Vessel ◽

Dynamic Susceptibility ◽

Collateral Flow ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Perfusion Weighted Imaging

Background and Purpose— In acute stroke patients with large vessel occlusion, the goal of intravenous thrombolysis (IVT) is to achieve early recanalization (ER). Apart from occlusion site and thrombus length, predictors of early post-IVT recanalization are poorly known. Better collaterals might also facilitate ER, for instance, by improving delivery of the thrombolytic agent to both ends of the thrombus. In this proof-of-concept study, we tested the hypothesis that good collaterals independently predict post-IVT recanalization before thrombectomy. Methods— Patients from the registries of 6 French stroke centers with the following criteria were included: (1) acute stroke with large vessel occlusion treated with IVT and referred for thrombectomy between May 2015 and March 2017; (2) pre-IVT brain magnetic resonance imaging, including diffusion-weighted imaging, T2*, MR angiography, and dynamic susceptibility contrast perfusion-weighted imaging; and (3) ER evaluated ≤3 hours from IVT start on either first angiographic run or noninvasive imaging. A collateral flow map derived from perfusion-weighted imaging source data was automatically generated, replicating a previously validated method. Thrombus length was measured on T2*-based susceptibility vessel sign. Results— Of 224 eligible patients, 37 (16%) experienced ER. ER occurred in 10 of 83 (12%), 17 of 116 (15%), and 10 of 25 (40%) patients with poor/moderate, good, and excellent collaterals, respectively. In multivariable analysis, better collaterals were independently associated with ER ( P =0.029), together with shorter thrombus ( P <0.001) and more distal occlusion site ( P =0.010). Conclusions— In our sample of patients with stroke imaged with perfusion-weighted imaging before IVT and intended for thrombectomy, better collaterals were independently associated with post-IVT recanalization, supporting our hypothesis. These findings strengthen the idea that advanced imaging may play a key role for personalized medicine in identifying patients with large vessel occlusion most likely to benefit from IVT in the thrombectomy era.

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ASSOCIATIONS OF CLINICAL AND IMAGING CHARACTERISTICS WITH COLLATERAL GRADE ON BASELINE CT ANGIOGRAPHY IN PATIENTS WITHC ACUTE ISCHEMIC STROKE DUE TO LARGE VESSEL OCCLUSION

10.26226/morressier.5ab8f560d462b8029238ccc4 ◽

2018 ◽

Author(s):

Bob Roozenbeek

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Ct Angiography ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Imaging Characteristics

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Abstract P340: Chronic Cerebrovascular Damage and Acute Embolic Mechanisms Associated With Acute Leptomeningeal Collateral Flow in Embolic Large Vessel Occlusion

Stroke ◽

10.1161/str.52.suppl_1.p340 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Tetsuya Hashimoto ◽

Takenobu Kunieda ◽

Tristan Honda ◽

Fabien Scalzo ◽

Latisha K Sharma ◽

...

Keyword(s):

Time Course ◽

Multivariate Logistic Regression Analysis ◽

Blood Perfusion ◽

Large Vessel ◽

Cardioembolic Stroke ◽

Collateral Flow ◽

Large Vessel Occlusion ◽

Stroke Subtype ◽

Anterior Circulation ◽

Vessel Occlusion

Background and Purpose: Acute leptomeningeal collateral flow is vital to maintain blood perfusion to penumbral tissue in acute ischemic stroke due to large vessel occlusion (LVO). However, the degree of this collateral flow differs among patients. Patient premorbid factors as well as factors caused by the mechanisms of stroke are expected to be associated with this collateral flow. We aimed to investigate the clinical determinants of acute leptomeningeal collateral flow in embolic LVO. Methods: Among consecutive stroke patients caused by acute embolic anterior circulation LVO, we retrospectively reviewed 108 patients who underwent evaluation of acute leptomeningeal collateral status (CS) on pretreatment CTA admitted from January 2015 to December 2019. Both premorbid information including cerebrovascular risk factors and leukoaraiosis evaluated by the total white matter (WM) Fazekas score on MRI, which was calculated as periventricular plus deep WM scores, and stroke related information including stroke subtypes, severity, time course, and occlusive thrombus characteristics were collected. Among thrombus characteristics, thrombus length was measured by tracing the filling defect of contrast on CTA. The clinical determinants of good leptomeningeal CS (> 50% collateral filling of the occluded territory) were analyzed. Results: CS was good in 67 patients (62%). On multivariate logistic regression analysis, cardioembolic stroke subtype was negatively related (OR, 0.170; 95% CI, 0.022-0.868), and mild leukoaraiosis (total WM Fazekas scores of 0-2) was positively related (OR, 9.57; 95% CI, 2.49-47.75) to good CS. On subgroup analysis limited to 82 patients with cardioembolic stroke, shorter thrombus length (OR, 0.913 per mm increase; 95% CI, 0.819-0.999) as well as mild leukoaraiosis (OR, 5.79; 95% CI, 1.40-29.61) were independently related to good CS. Conclusions: Premorbid leukoaraiosis and cardioembolic etiology are determinants of acute leptomeningeal collateral flow in embolic LVO. In addition, thrombus length is also a determinant of collateral flow in cardioembolic LVO. These findings indicate that a combination of chronic cerebrovascular damage and acute embolic mechanisms could determine the degree of leptomeningeal collateral flow.

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Reduced Leukoaraiosis, Noncardiac Embolic Stroke Etiology, and Shorter Thrombus Length Indicate Good Leptomeningeal Collateral Flow in Embolic Large-Vessel Occlusion

American Journal of Neuroradiology ◽

10.3174/ajnr.a7360 ◽

2021 ◽

Author(s):

T. Hashimoto ◽

T. Kunieda ◽

T. Honda ◽

F. Scalzo ◽

L. Ali ◽

...

Keyword(s):

Embolic Stroke ◽

Large Vessel ◽

Collateral Flow ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Stroke Etiology

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Abstract P337: RAPID-LVO for Automated Detection of Intracranial Large Vessel Occlusion in Ct Angiography of the Brain

Stroke ◽

10.1161/str.52.suppl_1.p337 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Seena Dehkharghani ◽

Maarten G Lansberg ◽

Chitra Venkatsubramanian ◽

carlo W cereda ◽

Fabricio O Lima ◽

...

Keyword(s):

Ct Angiography ◽

Sensitivity And Specificity ◽

Large Vessel ◽

Receiver Operating Characteristics ◽

Subspecialty Training ◽

Emergency Setting ◽

Large Vessel Occlusion ◽

Operating Characteristics ◽

Vessel Occlusion ◽

Receiver Operating

Background: Identification of large vessel occlusion (LVO) is paramount in the urgent evaluation of acute ischemic stroke (AIS). Emergent interpretation of large and high-complexity data sets, however, may impose strains upon imaging and clinical workflows, motivating development of fast and accurate computer-aided approaches to facilitate LVO detection in the emergency setting. This study investigates the performance of a fully automated LVO detection platform in a mixed cohort of stroke subjects with and without LVO on head and neck CT angiography (CTA). Methods: CTA from two cerebrovascular trials were enriched with cases from eleven global sites. Imaging and clinical variables were balanced between populations including in LVO positivity and across demographic and imaging environments to the extent achievable. Independent and fully blinded review for intracranial ICA or MCA M1 LVO was performed by two subspecialty neuroradiologists. A novel, user-independent imaging analysis application ( RAPID-LVO , iSchemaview inc) was used to predict LVO presence, location, and overall performance relative to reader consensus. Any discordance between readers was adjudicated by a blinded tertiary reader with subspecialty training. Sensitivity, specificity, and receiver-operating characteristics were determined by an independent statistician. Performance thresholds were set a priori, including a lower bound of the 95% CI of sensitivity and specificity of ≥0.8 at mean times-to-notification <3.5 minutes. Results: 217 CTA (median age 65.5, 53% male, 109 LVO(+)) were included. Lower confidence limits of sensitivity and specificity exceeded 90% (sensitivity 0.963, 95% CI 0.909-0.986; specificity 0.981, 95% CI 0.935-0.995), surpassing pre-specified performance benchmarks. Subgroup analyses revealed no decrement in performance relative to subject age or sex, vendor systems, or location of the examination within or outside the United States. The area under the receiver operating characteristics curve was 0.99 (95% CI: 0.971-0.999) and average time-to-notification was 3.18 minutes. Conclusion: RAPID-LVO offers fast, highly accurate, and fully user-independent large vessel occlusion detection across all tested clinical and imaging environments.

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