Efficacy of Peripheral Interventional Radiologists Performing Endovascular Stroke Therapy Guided by CT Perfusion Triage of Patients

Introduction: CT Perfusion (CTP) is frequently used to evaluate patients with large vessel occlusion (LVO) acute ischemic stroke (AIS) for possible endovascular stroke therapy (EST). However, the accuracy of its infarct core and penumbral predictions are uncertain, and as such, may rule out patients who would otherwise have received EST without CTP-based selection. Methods: From our prospectively maintained multicenter registry, we identified AIS patients between January 2018 and February 2019. Data were collected from 4 comprehensive stroke centers - one center often performs CTP on nearly all AIS evaluations (CTP-H) and 3 centers perform CTP for uncertain findings on non-contrast CT (CTP-L). All 4 CSCs are covered by a single group of Vascular Neurologists and NeuroInterventionists with standardization of quality practices. Logistic regression adjusted for age, NIHSS, CT ASPECTS as ordinal variables, time of presentation (0-6 hrs. vs 6-24 hrs.), and occlusion location was used to assess the likelihood of undergoing EST. Results are provided as median [IQR] and OR [95% CI]. Results: Among 2,317 patients with AIS, median age was 67 [57-78], 48% were female and 48% were white. The CTP rates at the 3 CTP-L centers were 18%, 31%, and 36%, while CTP rate at CTP-H center was 74% among all AIS patients (p<0.0001). 309 (43%) patients with LVO presented to CTP-L centers and 404 (57%) to the CTP-H center. For LVO patients presenting at CTP-L centers, median age was 70 [60-80], 52% were female, and 42% were white, while at CTP-H center median age was 68 [59-78], 44% were female and 57% were white. ASPECTS scores (CTP-L 9 [7-10] vs CTP-H 8 [6-9], p>0.05) and proportion of ICA/MCA occlusions (72% vs 77%; p>0.05), were comparable among centers, but LVO patients presenting at CTP-L centers had a lower NIHSS (11[4-18] vs 14[7-20]; p<0.01). For patients presenting 0-6 hrs, a higher number presented at the CTP-H center (20% vs 27%; p<0.05). In adjusted logistic regression, patients presenting with LVO to the CTP-H center were less likely to undergo EST (OR 0.51 [0.29-0.89]; p<0.05). Conclusion: In this study of 4 CSCs staffed by the same group of physicians, routine utilization of CTP in EST patient selection was associated with reduced likelihood of EST in patients with LVO.

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Blood Pressure After Endovascular Stroke Therapy-II

Case Medical Research ◽

10.31525/ct1-nct04116112 ◽

2019 ◽

Author(s):

Keyword(s):

Blood Pressure ◽

Stroke Therapy ◽

Endovascular Stroke Therapy

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Abstract WP23: Comparison of Suction Thrombectomy, Stentriever, and Combined Approach: Thrombus Size, Fragmentation, and Outcome - A Single Center Analysis

Stroke ◽

10.1161/str.48.suppl_1.wp23 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Wolfgang Leesch ◽

Pankajavalli Ramakrishnan ◽

Dean Kostov ◽

O’Brien Gossage ◽

Frank Sanderson

Keyword(s):

Clinical Outcome ◽

Combined Approach ◽

Stroke Therapy ◽

Distal Embolization ◽

Radiographic Images ◽

Single Pass ◽

Size Number ◽

Data Points ◽

Combined Technique ◽

Endovascular Stroke Therapy

Introduction: Few reports have compared the commonly used technical approaches of stentriever, suction thrombectomy, and combined technique, particularly with emphasis on thrombus volume, fragmentation, distal embolization, and clinical outcome. Methods: Medical records and radiographic images of patients undergoing endovascular stroke therapy at our institution between 2014 and 2015 were reviewed for the following data points: Patient age, sex, NIH stroke scale (NIHSS) at presentation, number of passes, presence of distal embolization on angiography, TICI score, and Modified Rankin Scale (MRS) at discharge. When available, photographic images of the retrieved thrombus were analyzed for number of fragments and size of the largest fragment. Parameters were compared for the three thrombectomy techniques of suction (ADAPT technique), stentriever, and the combined approach. Results: Of 63 patients receiving endovascular stroke therapy, 47 (75%) underwent mechanical thrombectomy: Stentriever 17 (36%), Suction 18 (38%), and combined 12 (26%). Average age and presenting NIH stroke scales were similar in the groups. A single pass thrombectomy was more common in the suction group (72%) than in the stentriever (29%) and combined groups (8%). There were more thrombus fragments in the stentriever (2.3) and combined groups (3.4) than in the suction group (1.4), correlating to more frequent distal embolization (suction 22%, stentriever 70%, combined 50%). The retrieved thrombus was largest in the suction group (12.9 mm; stentriever 6.6 mm; combined 10.4 mm). Overall outcome at discharge was better in the suction group (61% MRS 0-2) than in the stentriever (35%) and combined groups (17%). Conclusions: In our patient sample suction thrombectomy outperformed the stentriever and combined techniques in the categories of achieved reperfusion grade, single pass, retrieved thrombus size, number of fragments, distal embolization and clinical outcome. While stent retriever and suction thrombetomy were used as primary approaches, the combined technique was commonly utilized as a rescue attempt once the primary approach had failed, constituting a potential limitation of the analysis in this category.

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Abstract 3268: Ct Perfusion As A Tool To Predict The Risk Of Hemorrhagic Transformation In Ischemic Stroke Treated With Tissue Plasminogen Activator: A Single Center Experience.

Stroke ◽

10.1161/str.43.suppl_1.a3268 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Tareq Kass-Hout ◽

Maxim Mokin ◽

Omar Kass-Hout ◽

Emad Nourollahzadeh ◽

David Wack ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Stroke ◽

Brain Tissue ◽

Cerebral Blood Volume ◽

Ct Perfusion ◽

Intravenous Thrombolysis ◽

Hemorrhagic Transformation ◽

Stroke Therapy ◽

Two Phase ◽

The Mean

Objective: To use the Computed Tomography Perfusion (CTP) parameters at the time of hospital admission, including Cerebral Blood Volume (CBV) and Permeability Surface area product (PS), to identify patients with higher risk to develop hemorrhagic transformation in the setting of acute stroke therapy with intravenous thrombolysis. Methods: Retrospective study that compared admission CTP variables between patients with Hemorrhagic Transformation (HT) acute stroke and those with no hemorrhagic transformation. Both groups received standard of care intravenous thrombolysis with tPA. Twenty patients presented to our stroke center between the years 2007 - 2011 within 3 hours after stroke symptoms onset. All patients underwent two-phase 320 slice CTP which creates CBV and PS measurements. Patients were divided into two groups according to whether or not they had HT on a follow up CT head without contrast, done within 36 hours of the thrombolysis therapy. Clinical, demographic and CTP variables were compared between the HT and non-HT groups using logistic regression analyses. Results: HT developed in 8 (40%) patients. Patients with HT had lower ASPECT score ( P =.03), higher NIHSS on admission ( P= .01) and worse outcome ( P= .04) compared to patients who did not develop HT. Baseline blood flow defects were comparable between the two groups. The mean PS for the HT group was 0.53 mL/min/100g brain tissue, which was significantly higher than that for the non-HT group of 0.04 mL/min/100g brain tissue ( P <.0001). The mean area under the curve was 0.92 (95% CI). The PS threshold of 0.26 mL/min/100g brain tissue had a sensitivity of 80% and a specificity of 92% for detecting patients with high risk of hemorrhagic transformation after intravenous thrombolysis. Conclusions: Admission CTP measurements might be useful to predict patients who are at higher risk to develop hemorrhagic transformation after acute ischemic stroke therapy.

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Abstract 96: CTP-Mismatch Maps Improve Interobserver Agreement

Stroke ◽

10.1161/str.43.suppl_1.a96 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Waimei A Tai ◽

Archana Purushotham ◽

Matus Straka ◽

Rebecca M Sugg ◽

Naveed Akhtar ◽

...

Keyword(s):

Acute Stroke ◽

Ct Perfusion ◽

Interobserver Reliability ◽

Observer Agreement ◽

Absolute Difference ◽

Stroke Therapy ◽

Adequate Quality ◽

Ischemic Core ◽

Observer Disagreement ◽

Acute Stroke Therapy

Introduction: The use of mismatch between the ischemic core and penumbra to select patients who are likely to benefit from acute stroke therapy has gained popularity. Interpretation of the ischemic core and penumbra on standard CT-perfusion (CTP) maps is subjective. This may lead to variability among physicians in the decision if a patient is a good candidate for acute stroke therapy. A CTP-Mismatch map with outlines of the ischemic core and penumbra could limit this variability. The goal of this study was to determine if inter-observer agreement regarding a patient’s suitability for acute stroke therapy improves with the use of a CTP-Mismatch map. The figure shows a typical CTP-Mismatch map. Methods: Ninety-six consecutive patients evaluated with CTP prior to intra-arterial therapy at St. Lukes Hospital in 2008-09 were included. 79 patients had adequate quality CTP for this analysis. Standard CTP maps (CBV, CBF, MTT, and Tmax) and a CTP-Mismatch map were generated with a fully automated program for processing of CTP source images (RAPID). RAPID assessed the ischemic core using a CBF threshold <30% of the contralateral hemisphere (rCBF<30%). The ischemic penumbra was defined by a Tmax threshold of >6 sec (Tmax>6s). The standard CTP maps and the CTP-Mismatch map were independently analyzed by two vascular neurologists in a blinded fashion. The raters assessed a patient's suitability for intra-arterial therapy based on the following mismatch criteria: (1) a ratio between (Tmax>6s) and (rCBF<30%) volumes >1.8 and (2) an absolute difference between (Tmax>6s) and (CBF<30%) volumes >15ml. Interobserver reliability was assessed with Cohen’s kappa. Results: When assessment of suitability for intra-arterial therapy was based on interpretation of standard CTP maps, the two raters agreed in 58 of 79 patients (kappa=0.46; 95% CI=0.24-0.60). The agreement between observers improved when suitability was determined using CTP-Mismatch maps (agreement in 76 of 79 cases; kappa=0.92; 95% CI=0.75-0.92; p<0.001 for difference between kappa values). The 3 cases with inter-observer disagreement had artifact on the CTP-Mismatch map. Following concensus adjudication of these 3 cases, 40 of the 79 patients (51%) were deemed suitable candidates for acute stroke therapy. Conclusion: CTP-Mismatch maps with estimates of ischemic core and penumbra volumes markedly improve inter-observer agreement regarding assessment of suitability for acute stroke therapy. Such maps, which can be generated automatically, may help standardize decision making algorithms for evaluation of potential intra-arterial therapy candidates.

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Optimal anesthetic strategy for endovascular stroke therapy

Neurology ◽

10.1212/wnl.0000000000005754 ◽

2018 ◽

Vol 91 (1) ◽

pp. 16-18 ◽

Cited By ~ 1

Author(s):

Alejandro A. Rabinstein ◽

David F. Kallmes

Keyword(s):

Stroke Therapy ◽

Endovascular Stroke Therapy

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Abstract WP121: Incorporating CT-Perfusion Imaging in Acute Stroke Therapy Workflow Does Not Delay Door to Needle Time for Intravenous t-PA

Stroke ◽

10.1161/str.51.suppl_1.wp121 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Bahareh Sianati ◽

Russel Cerejo ◽

David Wright ◽

Ashish Tayal ◽

Patty Noah ◽

...

Keyword(s):

Acute Stroke ◽

Perfusion Imaging ◽

Ct Perfusion ◽

Brain Perfusion ◽

Stroke Therapy ◽

Brain Perfusion Imaging ◽

Group 2 ◽

Acute Stroke Therapy ◽

Iv Tpa ◽

Group 1

Introduction: Brain perfusion imaging has become an integral part of acute stroke therapy, especially for the extended time window. A streamlined workflow is essential to reduce delays in acute stroke therapy. Incorporating standard and advanced imaging together may reduce time to endovascular therapy but may delay administration of intravenous (IV) tPA. Method: A retrospective analysis of all acute stroke therapy cases between August 2017 and March of 2018 was performed at a single stroke center. Brain perfusion imaging was instituted into the workflow in December of 2017. We included patients who received IV tPA before and after implementation of CT perfusion (CT-P). Demographics, clinical presentation, stroke treatment times and imaging characteristics were collected. Results: During the eight-month period, we identified 117 patients who met inclusion criteria. We divided the cohort into two groups, pre CT-P implementation (Group 1) and post CT-P implementation (Group 2). We identified 66 patients in Group 1 and 51 patients in Group 2. In Group 1, 29 (44%) were females with median age of 63 years. In Group 2, 33 (65%) were females, with median age of 72 years. There was no difference in median times for door to needle in Group 1 (57 minutes, interquartile range [IQR] 42 – 76) compared to Group 2 (53 minutes, [IQR] 40 – 68) ( P = 0.20). Conclusion: Incorporating CT-P in the imaging workflow did not delay door to needle time for IV tPA in acute stroke therapy.

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