Comparison of CT angiography collaterals for predicting target perfusion profile and clinical outcome in patients with acute ischemic stroke

Background: CT angiography (CTA) and CT perfusion (CTP) are important diagnostic tools in acute ischemic stroke. We investigated the prognostic value of CTA and CTP for clinical outcome and determined whether they have additional prognostic value over patient characteristics and non-contrast CT (NCCT). Methods: We included 1,374 patients with suspected acute ischemic stroke in the prospective multicenter Dutch acute stroke study. Sixty percent of the cohort was used for deriving the predictors and the remaining 40% for validating them. We calculated the predictive values of CTA and CTP predictors for poor clinical outcome (modified Rankin Scale score 3-6). Associations between CTA and CTP predictors and poor clinical outcome were assessed with odds ratios (OR). Multivariable logistic regression models were developed based on patient characteristics and NCCT predictors, and subsequently CTA and CTP predictors were added. The increase in area under the curve (AUC) value was determined to assess the additional prognostic value of CTA and CTP. Model validation was performed by assessing discrimination and calibration. Results: Poor outcome occurred in 501 patients (36.5%). Each of the evaluated CTA measures strongly predicted outcome in univariable analyses: the positive predictive value (PPV) was 59% for Alberta Stroke Program Early CT Score (ASPECTS) ≤7 on CTA source images (OR 3.3; 95% CI 2.3-4.8), 63% for presence of a proximal intracranial occlusion (OR 5.1; 95% CI 3.7-7.1), 66% for poor leptomeningeal collaterals (OR 4.3; 95% CI 2.8-6.6), and 58% for a >70% carotid or vertebrobasilar stenosis/occlusion (OR 3.2; 95% CI 2.2-4.6). The same applied to the CTP measures, as the PPVs were 65% for ASPECTS ≤7 on cerebral blood volume maps (OR 5.1; 95% CI 3.7-7.2) and 53% for ASPECTS ≤7 on mean transit time maps (OR 3.9; 95% CI 2.9-5.3). The prognostic model based on patient characteristics and NCCT measures was highly predictive for poor clinical outcome (AUC 0.84; 95% CI 0.81-0.86). Adding CTA and CTP predictors to this model did not improve the predictive value (AUC 0.85; 95% CI 0.83-0.88). In the validation cohort, the AUC values were 0.78 (95% CI 0.73-0.82) and 0.79 (95% CI 0.75-0.83), respectively. Calibration of the models was satisfactory. Conclusions: In patients with suspected acute ischemic stroke, admission CTA and CTP parameters are strong predictors of poor outcome and can be used to predict long-term clinical outcome. In multivariable prediction models, however, their additional prognostic value over patient characteristics and NCCT is limited in an unselected stroke population.

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Collateral score on CT angiography in patients with acute ischemic stroke - A retrospective study.

Journal Of Cardiovascular, Neurovascular & Stroke ◽

10.32896/cvns.11.1-7 ◽

2019 ◽

pp. 1-7

Author(s):

Mathan Raj ◽

Shahizon Azura Mukari ◽

Wan Asyraf Wan Zaidi ◽

Ahmad Sobri Muda

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Ct Angiography ◽

Area Under The Curve ◽

Clinical Information ◽

Poor Clinical Outcome ◽

The Status ◽

Potential Use ◽

Prognostic Data

Objective: Clinically assessing the status of cerebral collaterals is thought to provide invaluable diagnostic and prognostic data in managing acute ischemic stroke (AIS) patients. In this study we present a report, based on commonly used collateral grading system, assessing the correlation between the collateral status seen on CT angiography and patients’ functional outcome at Day 90 in our institution. Method: Patients presenting to the Emergency Department within 6 hours of onset of stroke from January 2010 until December 2014 were chosen for the study. CT angiography source images were retrospectively reviewed and given a “collateral score” (CS) by a radiologist who was blinded to the patient’s clinical information on presentation, as well as the clinical outcomes at 90 days. Patients’ mRS score at 90 days was obtained retrospectively and compared against the “collateral score”. Results: 87 patients were enrolled into this study, of which 60 (69%) were male and 27 (31%) were female with a mean age of 60.3 years. In this study, 56 (64.4%) patients had a collateral score (CS) ? 2 and 31 (35.6%) patients had a CS < 2. Out of 56 patients who had a CS ? 2, 51 of them (91%) had good clinical outcome with a mRS ? 2. All the patients who had CS < 2 showed poor clinical outcome with a mRS > 2. The collateral score predicts accurately the clinical outcome with an area under the curve (ROC) of 0.75 (95% CI, 0.675-0.871, P=0.001). There is significant Spearman correlation between CS and the clinical outcome at Day 90, in patients with AIS during CTA analysis. Conclusion: Our data supports the potential use of CS analysis in predicting clinical outcome of patients with AIS. Nevertheless, further study on a larger scale is strongly suggested to verify the reliability and reproducibility of CS assessment in CTA analysis prior to reperfusion in AIS patients.

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Collateral score on CT angiography in patients with acute ischemic stroke - A retrospective study

Journal Of Cardiovascular, Neurovascular & Stroke ◽

10.32896/cvns.v1n1.1-7 ◽

2019 ◽

Vol 1 (1) ◽

pp. 1-7 ◽

Cited By ~ 1

Author(s):

Mathan Raj ◽

Shahizon Azura Mukari ◽

Wan Asyraf Wan Zaidi ◽

Ahmad Sobri Muda

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Ct Angiography ◽

Area Under The Curve ◽

Clinical Information ◽

Poor Clinical Outcome ◽

The Status ◽

Potential Use ◽

Prognostic Data

Objective: Clinically assessing the status of cerebral collaterals is thought to provide invaluable diagnostic and prognostic data in managing acute ischemic stroke (AIS) patients. In this study we present a report, based on commonly used collateral grading system, assessing the correlation between the collateral status seen on CT angiography and patients’ functional outcome at Day 90 in our institution. Method: Patients presenting to the Emergency Department within 6 hours of onset of stroke from January 2010 until December 2014 were chosen for the study. CT angiography source images were retrospectively reviewed and given a “collateral score” (CS) by a radiologist who was blinded to the patient’s clinical information on presentation, as well as the clinical outcomes at 90 days. Patients’ mRS score at 90 days was obtained retrospectively and compared against the “collateral score”. Results: 87 patients were enrolled into this study, of which 60 (69%) were male and 27 (31%) were female with a mean age of 60.3 years. In this study, 56 (64.4%) patients had a collateral score (CS) ? 2 and 31 (35.6%) patients had a CS < 2. Out of 56 patients who had a CS ? 2, 51 of them (91%) had good clinical outcome with a mRS ? 2. All the patients who had CS < 2 showed poor clinical outcome with a mRS > 2. The collateral score predicts accurately the clinical outcome with an area under the curve (ROC) of 0.75 (95% CI, 0.675-0.871, P=0.001). There is significant Spearman correlation between CS and the clinical outcome at Day 90, in patients with AIS during CTA analysis. Conclusion: Our data supports the potential use of CS analysis in predicting clinical outcome of patients with AIS. Nevertheless, further study on a larger scale is strongly suggested to verify the reliability and reproducibility of CS assessment in CTA analysis prior to reperfusion in AIS patients.

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Evaluation of the clot burden score (cbs) for acute ischemic stroke (ais) in intent-to-treat patients.

Journal Of Cardiovascular, Neurovascular & Stroke ◽

10.32896/cvns.v1n1.11-15 ◽

2019 ◽

Vol 1 (1) ◽

pp. 11-15 ◽

Cited By ~ 1

Author(s):

Sarah Yaziz ◽

Ahmad Sobri Muda ◽

Wan Asyraf Wan Zaidi ◽

Nik Azuan Nik Ismail

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Predictive Value ◽

Area Under The Curve ◽

Rank Correlation ◽

Treatment Decision ◽

Roc Curves ◽

Significant Negative Correlation ◽

Clot Burden

Background : The clot burden score (CBS) is a scoring system used in acute ischemic stroke (AIS) to predict patient outcome and guide treatment decision. However, CBS is not routinely practiced in many institutions. This study aimed to investigate the feasibility of CBS as a relevant predictor of good clinical outcome in AIS cases. Methods: A retrospective data collection and review of AIS patients in a teaching hospital was done from June 2010 until June 2015. Patients were selected following the inclusion and exclusion criteria. These patients were followed up after 90 days of discharge. The Modified Rankin scale (mRS) was used to assess their outcome (functional status). Linear regression Spearman Rank correlation was performed between the CBS and mRS. The quality performance of the correlations was evaluated using Receiver operating characteristic (ROC) curves. Results: A total of 89 patients with AIS were analysed, 67.4% (n=60) male and 32.6% (n=29) female. Twenty-nine (29) patients (33.7%) had a CBS ?6, 6 patients (6.7%) had CBS <6, while 53 patients (59.6%) were deemed clot free. Ninety (90) days post insult, clinical assessment showed that 57 (67.6%) patients were functionally independent, 27 (30.3%) patients functionally dependent, and 5 (5.6%) patients were deceased. Data analysis reported a significant negative correlation (r= -0.611, p<0.001). ROC curves analysis showed an area under the curve of 0.81 at the cut-off point of 6.5. This showed that a CBS of more than 6 predicted a good mRS clinical outcome in AIS patients; with sensitivity of 98.2%, specificity of 53.1%, positive predictive value (PPV) of 76%, and negative predictive value (NPV) of 21%. Conclusion: CBS is a useful additional variable for the management of AIS cases, and should be incorporated into the routine radiological reporting for acute ischemic stroke (AIS) cases.

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Association between Blood Urea Nitrogen-to-creatinine Ratio and Three-Month Outcome in Patients with Acute Ischemic Stroke

Current Neurovascular Research ◽

10.2174/1567202616666190412123705 ◽

2019 ◽

Vol 16 (2) ◽

pp. 166-172 ◽

Cited By ~ 1

Author(s):

Linghui Deng ◽

Changyi Wang ◽

Shi Qiu ◽

Haiyang Bian ◽

Lu Wang ◽

...

Keyword(s):

Logistic Regression ◽

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Blood Urea Nitrogen ◽

Univariate Analysis ◽

Density Lipoprotein ◽

Hydration Status ◽

Creatinine Ratio ◽

Urea Nitrogen

Background: Hydration status significantly affects the clinical outcome of acute ischemic stroke (AIS) patients. Blood urea nitrogen-to-creatinine ratio (BUN/Cr) is a biomarker of hydration status. However, it is not known whether there is a relationship between BUN/Cr and three-month outcome as assessed by the modified Rankin Scale (mRS) score in AIS patients. Methods: AIS patients admitted to West China Hospital from 2012 to 2016 were prospectively and consecutively enrolled and baseline data were collected. Poor clinical outcome was defined as three-month mRS > 2. Univariate and multivariate logistic regression analyses were performed to determine the relationship between BUN/Cr and three-month outcome. Confounding factors were identified by univariate analysis. Stratified logistic regression analysis was performed to identify effect modifiers. Results: A total of 1738 patients were included in the study. BUN/Cr showed a positive correlation with the three-month outcome (OR 1.02, 95% CI 1.00-1.03, p=0.04). However, after adjusting for potential confounders, the correlation was no longer significant (p=0.95). An interaction between BUN/Cr and high-density lipoprotein (HDL) was discovered (p=0.03), with a significant correlation between BUN/Cr and three-month outcome in patients with higher HDL (OR 1.03, 95% CI 1.00-1.07, p=0.04). Conclusion: Elevated BUN/Cr is associated with poor three-month outcome in AIS patients with high HDL levels.

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Efficacy of Mechanical Thrombectomy using Penumbra ACETM Aspiration Catheter Compared to Stent Retriever SolitaireTM FR in Patients with Acute Ischemic Stroke

Brain Sciences ◽

10.3390/brainsci11040504 ◽

2021 ◽

Vol 11 (4) ◽

pp. 504

Author(s):

Dalibor Sila ◽

Markus Lenski ◽

Maria Vojtková ◽

Mustafa Elgharbawy ◽

František Charvát ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Mechanical Thrombectomy ◽

Binary Logistic Regression ◽

Stent Retriever ◽

Good Clinical Outcome ◽

Significant Difference ◽

Aspiration Technique

Background: Mechanical thrombectomy is the standard therapy in patients with acute ischemic stroke (AIS). The primary aim of our study was to compare the procedural efficacy of the direct aspiration technique, using Penumbra ACETM aspiration catheter, and the stent retriever technique, with a SolitaireTM FR stent. Secondarily, we investigated treatment-dependent and treatment-independent factors that predict a good clinical outcome. Methods: We analyzed our series of mechanical thrombectomies using a SolitaireTM FR stent and a Penumbra ACETM catheter. The clinical and radiographic data of 76 patients were retrospectively reviewed. Using binary logistic regression, we looked for the predictors of a good clinical outcome. Results: In the Penumbra ACETM group we achieved significantly higher rates of complete vessel recanalization with lower device passage counts, shorter recanalization times, shorter procedure times and shorter fluoroscopy times (p < 0.001) compared to the SolitaireTM FR group. We observed no significant difference in good clinical outcomes (52.4% vs. 56.4%, p = 0.756). Predictors of a good clinical outcome were lower initial NIHSS scores, pial arterial collateralization on admission head CT angiography scan, shorter recanalization times and device passage counts. Conclusions: The aspiration technique using Penumbra ACETM catheter is comparable to the stent retriever technique with SolitaireTM FR regarding clinical outcomes.

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Impact of Early Blood Pressure Lowering in Patients Presenting with Acute Ischemic Stroke

Current Cardiology Reports ◽

10.1007/s11886-021-01497-0 ◽

2021 ◽

Vol 23 (6) ◽

Author(s):

A. Maud ◽

G. J. Rodriguez ◽

A. Vellipuram ◽

F. Sheriff ◽

M. Ghatali ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Negative Impact ◽

Systemic Blood Pressure ◽

Hemodynamic Response ◽

Collateral Flow ◽

Early Management ◽

Ischemic Tissue

Abstract Purpose of Review In this review article we will discuss the acute hypertensive response in the context of acute ischemic stroke and present the latest evidence-based concepts of the significance and management of the hemodynamic response in acute ischemic stroke. Recent Findings Acute hypertensive response is considered a common hemodynamic physiologic response in the early setting of an acute ischemic stroke. The significance of the acute hypertensive response is not entirely well understood. However, in certain types of acute ischemic strokes, the systemic elevation of the blood pressure helps to maintain the collateral blood flow in the penumbral ischemic tissue. The magnitude of the elevation of the systemic blood pressure that contributes to the maintenance of the collateral flow is not well established. The overcorrection of this physiologic hemodynamic response before an effective vessel recanalization takes place can carry a negative impact in the final clinical outcome. The significance of the persistence of the acute hypertensive response after an effective vessel recanalization is poorly understood, and it may negatively affect the final outcome due to reperfusion injury. Summary Acute hypertensive response is considered a common hemodynamic reaction of the cardiovascular system in the context of an acute ischemic stroke. The reaction is particularly common in acute brain embolic occlusion of large intracranial vessels. Its early management before, during, and immediately after arterial reperfusion has a repercussion in the final fate of the ischemic tissue and the clinical outcome.

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Abstract 74: Early Arterial Recanalization After Intra-venous Tissue-Plasminogen-Activator Treatment in the Interventional Management of Stroke-3 Study

Stroke ◽

10.1161/str.45.suppl_1.74 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Ruediger Von Kummer ◽

Andrew M Demchuk ◽

Lydia D Foster ◽

Bernard Yan ◽

Wouter J Schonewille ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Internal Carotid ◽

Arterial Occlusion ◽

Posterior Circulation ◽

Stroke Patients ◽

Vessel Occlusion ◽

Tissue Plasminogen ◽

Arterial Recanalization

Background: Data on arterial recanalization after IV t-PA treatment are rare. IMS-3 allows the study of variables affecting arterial recanalization after IV t-PA in acute ischemic stroke patients with CTA-proved major artery occlusions. Methods: Of 656 acute ischemic stroke patients in IMS-3, 306 were examined with baseline CTA and randomized either to IV t-PA (N=95) or to IV t-PA followed by digital subtraction angiography (DSA) and endovascular therapy (EVT) (N=211). Comparison of baseline CTA to DSA within 5 hours of stroke onset assessed early arterial recanalization after IV t-PA. A central core lab categorized DSA vessel occlusion as “no, partial, or complete”. We studied the association between arterial occlusion sites on baseline CTA with early recanalization for the endovascular group and analyzed its impact on clinical outcome at 90 days. Results: In the EVT group, 22 patients (10.4%) had no CTA intracranial occlusions, but 1 extracranial occlusion; 42 patients (19.9%) had occlusions of intracranial internal carotid artery (ic-ICA); 10 patients (4.7%) had tandem occlusions of the cervical ICA and middle cerebral artery (MCA); 95 patients (45.0%) had MCA-trunk (M1) occlusions, 33 patients (15.6%) had M2 occlusions, 3 patients (1.4%) had M3/4 occlusions, and 6 patients (2.8%) occlusions within posterior circulation. Partial or complete recanalization occurred in 28.6% of patients before DSA and was marginally associated with occlusion site (p=0.0525) (8 patients (19.0%) with ic-ICA occlusion, 0 patients with tandem ICA/MCA occlusions, 34 patients (35.8%) with M1 occlusions, 11 patients (33.3%) with M2 occlusions, 0 patients with M3/4 occlusions, and 1 patient (16.7%) with occlusion within posterior circulation). Three CTA negative patients had intracranial occlusions on DSA. Thirty-two patients (59.3%) with early recanalization achieved mRS of 0-2 at 90 days compared to 51 patients (38.4%) without early recanalization (p=0.0099). There was no relationship between early recanalization and time to IV t-PA or mean t-PA dose. Conclusion: Before EVT, IV rt-PA may facilitate arterial recanalization and better clinical outcome in about one third of patients.

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Abstract W P37: Accuracy Of CT Angiography In The Localization Of Carotid Occlusion Sites In Acute Ischemic Stroke

Stroke ◽

10.1161/str.46.suppl_1.wp37 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Marcelo Rocha ◽

William T Delfyett ◽

Amin Aghaebrahim ◽

Ashutosh Jadhav ◽

Tudor Jovin

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Ct Angiography ◽

Target Lesion ◽

Carotid Occlusion ◽

Conventional Angiography ◽

Vessel Occlusion ◽

Cerebral Vessel ◽

Ct Angiogram ◽

Comprehensive Stroke Center

Background and Purpose: CT angiography yields rapid detection of a major cerebral vessel occlusion during the evaluation of patients with acute ischemic stroke leading to its widespread use in rapidly triaging for IA trial enrollment. In such trials, patients who have an extracranial carotid occlusion in tandem to the intracranial target lesion are typically excluded. However, ICA terminus occlusions may be misidentified as cervical carotid occlusions on CTA. The goal of this study is to determine the accuracy of CTA in identifying ICA terminus occlusions from tandem carotid occlusions (cervical and intracranial segments). Methods: Retrospective review of a prospectively maintained database containing patients treated at our comprehensive stroke center between 1996 and 2014 in whom catheter angiogram and CT angiogram were available on PACS. A Neuroradiologist, blinded to catheter angiographic results reviewed the CT angiography identifying the presence of intracranial stenoses and concomitant cervical carotid occlusions. Results: Of 196 patients presenting with intracranial carotid occlusions on catheter based angiogram, 101 patients were identified with good quality CT angiography and subsequent catheter angiograms. Mean ages for identified patients was 65 +/- 14, of which 52% women and 48% men. Forty-four percent of patients had an ASPECT score of 9-10. The overall rate of agreement between retrospective CTA and conventional angiography readings was 77%. Of 72 isolated intracranial occlusions on conventional angiography, CT angiography misidentified 23 cervical carotid occlusions. The sensitivity of CTA for detecting isolated carotid terminus occlusion was 68% in this cohort. Specific factors associated with CT and catheter based angiographic discrepancy are reviewed. Conclusions: The study raises systematic considerations for maximizing inclusion of patients with target arterial occlusions who are most likely to benefit from intra-arterial therapy in future clinical trials. Future steps will include determination of specificity, predictive value of CTA for localization of specific carotid occlusion sites. Clinical variables associated with lower CTA accuracy will also be examined.

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