Optimizing Outcome Prediction Scores in Patients Undergoing Endovascular Thrombectomy for Large Vessel Occlusions Using Collateral Grade on Computed Tomography Angiography

Neurosurgery ◽  
2018 ◽  
Vol 85 (3) ◽  
pp. 350-358
Author(s):  
Chang-Woo Ryu ◽  
Byung Moon Kim ◽  
Hyug-Gi Kim ◽  
Ji Hoe Heo ◽  
Hyo Suk Nam ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Computed Tomography Angiography ◽  
Outcome Prediction ◽  
Prediction Models ◽  
Large Vessel ◽  
Vascular Events ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Poor Outcomes

Abstract BACKGROUND Although several outcome prediction scores incorporated with pretreatment variables have been developed for acute ischemic stroke (AIS) patients, there is not currently a prediction score that includes pretreatment imaging that can show salvageable brain tissue. OBJECTIVE To evaluate whether addition of the collateral grade on computed tomography angiography to previously published prediction scores could increase accuracy of clinical outcome prediction in endovascular thrombectomy (EVT) for AIS. METHODS This study used a retrospective multicenter registry for patients undergoing EVT for anterior circulation large vessel occlusion. Three previously published outcome prediction scores (Houston intra-arterial therapy 2, HIAT2; totaled health risks in vascular events, THRIVE; and Pittsburgh response to endovascular therapy, PRE scores) were tested in this study. Using 482 deprivation cohorts, areas under the receiver operating characteristic curves (AUC-ROCs) were compared between prediction scores with/without collateral grades in predicting the poor outcomes (modified Rankin Scale 4-6 at 3-mo follow-up) after EVT. We developed modified prediction scores by adding the collateral grade, and their advancement of outcome prediction was validated using 208 independent validation cohorts. RESULTS AUC-ROCs of HIAT2, THRIVE, and PRE scores that incorporated with collateral grade were superior in predicting poor outcomes when compared to that of the unmodified scores (P < 0.001). In modified prediction models, 3, 3, and 10 points were added for poor collateral grade to HIAT2, THRIVE, and PRE score. Modified models outperformed unmodified models in testing of the validation cohorts (P < 0.001). CONCLUSION The addition of the collateral grade to outcome prediction scores resulted in better prediction of poor outcome after EVT for AIS compared to the prediction scores alone.

scholarly journals Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery

2021 ◽  
Author(s):  
Mohamad Abdalkader ◽  
Anurag Sahoo ◽  
Adam A. Dmytriw ◽  
Waleed Brinjikji ◽  
Guilherme Dabus ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Computed Tomography Angiography ◽  
Mechanical Thrombectomy ◽  
Posterior Cerebral Artery ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion

Abstract BACKGROUND Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety, and outcome of mechanical thrombectomy in acute FPCA occlusions. METHODS We performed a multicenter retrospective review of consecutive patients who underwent mechanical thrombectomy of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure computed tomography angiography or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different large vessel occlusion. Demographics, clinical presentation, imaging findings, endovascular treatment, and outcome were reviewed. RESULTS There were 25 patients with acute FPCA occlusion who underwent mechanical thrombectomy, distributed across 14 centers. Median National Institutes of Health Stroke Scale on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial computed tomography angiography in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. Thrombolysis in cerebral infarction 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intraprocedural complications. At 90 days, 48% (12/25) were functionally independent as defined by modified Rankin scale≤2. CONCLUSIONS Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the FPCA in patients presenting with anterior circulation stroke syndrome and patent anterior circulation. Novelty and significance This is the first multicenter study showing that thrombectomy of FPCA occlusion is feasible and safe.

Efficient Multimodal MRI Evaluation for Endovascular Thrombectomy of Anterior Circulation Large Vessel Occlusion

2020 ◽  
Vol 29 (12) ◽  
pp. 105271
Author(s):  
Kunakorn Atchaneeyasakul ◽  
David S. Liebeskind ◽  
Reza Jahan ◽  
Sidney Starkman ◽  
Latisha Sharma ◽  
...  
Keyword(s):  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Multimodal Mri ◽  
Mri Evaluation

scholarly journals Mobile Stroke Unit Computed Tomography Angiography Substantially Shortens Door-to-Puncture Time

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1613-1615 ◽  
Author(s):  
Alexandra L. Czap ◽  
Noopur Singh ◽  
Ritvij Bowry ◽  
Amanda Jagolino-Cole ◽  
Stephanie A. Parker ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Computed Tomography Angiography ◽  
Stroke Unit ◽  
Interquartile Range ◽  
National Institutes Of Health ◽  
Unique Identifier ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Unit Management ◽  
Mobile Stroke Unit

Background and Purpose— Endovascular thrombectomy (ET) door-to-puncture time (DTPT) is a modifiable metric. One of the most important, yet time-consuming steps, is documentation of large vessel occlusion by computed tomography angiography (CTA). We hypothesized that obtaining CTA on board a Mobile Stroke Unit and direct alert of the ET team shortens DTPT by over 30 minutes. Methods— We compared DTPT between patients having CTA onboard the Mobile Stroke Unit then subsequent ET from September 2018 to November 2019 and patients in Mobile Stroke Unit from August 2014 to August 2018, when onboard CTA was not yet being used. We also correlated DTPT with change in National Institutes of Health Stroke Scale between baseline and 24 hours. Results— Median DTPT was 53.5 (95% CI, 35–67) minutes shorter with onboard CTA and direct ET team notification: 41 minutes (interquartile range, 30.0–63.5) versus 94.5 minutes (interquartile range, 69.8–117.3; P <0.001). Median on-scene time was 31.5 minutes (interquartile range, 28.8–35.5) versus 27.0 minutes (interquartile range, 23.0–31.0) ( P <0.001). Shorter DTPT correlated with greater improvement of National Institutes of Health Stroke Scale (correlation=−0.2, P =0.07). Conclusions— Prehospital Mobile Stroke Unit management including on-board CTA and ET team alert substantially shortens DTPT. Registration— URL: https://clinicaltrials.gov ; Unique identifier: NCT02190500.

Leukoaraiosis and acute ischemic stroke: 90-day clinical outcome following endovascular recanalization, with proposed “L-ASPECTS”

2020 ◽  
pp. neurintsurg-2020-015957 ◽  
Author(s):  
John Benson ◽  
Seyed Mohammad Seyedsaadat ◽  
Ian Mark ◽  
Deena M Nasr ◽  
Alejandro A Rabinstein ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Mechanical Thrombectomy ◽  
Area Under The Curve ◽  
Primary Outcome Measure ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Endovascular Recanalization ◽  
Poor Outcomes

BackgroundTo assess if leukoaraiosis severity is associated with outcome in patients with acute ischemic stroke (AIS) following endovascular thrombectomy, and to propose a leukoaraiosis-related modification to the ASPECTS score.MethodsA retrospective review was completed of AIS patients that underwent mechanical thrombectomy for anterior circulation large vessel occlusion. The primary outcome measure was 90-day mRS. A proposed Leukoaraiosis-ASPECTS (“L-ASPECTS”) was calculated by subtracting from the traditional ASPECT based on leukoaraiosis severity (1 point subtracted if mild, 2 if moderate, 3 if severe). L-ASEPCTS score performance was validated using a consecutive cohort of 75 AIS LVO patients.Results174 patients were included in this retrospective analysis: average age: 68.0±9.1. 28 (16.1%) had no leukoaraiosis, 66 (37.9%) had mild, 62 (35.6%) had moderate, and 18 (10.3%) had severe. Leukoaraiosis severity was associated with worse 90-day mRS among all patients (P=0.0005). Both L-ASPECTS and ASPECTS were associated with poor outcomes, but the area under the curve (AUC) was higher with L-ASPECTS (P<0.0001 and AUC=0.7 for L-ASPECTS; P=0.04 and AUC=0.59 for ASPECTS). In the validation cohort, the AUC for L-ASPECTS was 0.79 while the AUC for ASPECTS was 0.70. Of patients that had successful reperfusion (mTICI 2b/3), the AUC for traditional ASPECTS in predicting good functional outcome was 0.80: AUC for L-ASPECTS was 0.89.ConclusionsLeukoaraiosis severity on pre-mechanical thrombectomy NCCT is associated with worse 90-day outcome in patients with AIS following endovascular recanalization, and is an independent risk factor for worse outcomes. A proposed L-ASPECTS score had stronger association with outcome than the traditional ASPECTS score.

Predictors of 30-day mortality after endovascular thrombectomy for large vessel occlusion in the elderly

2021 ◽  
pp. 159101992110692
Author(s):  
Yen-Jun Lai ◽  
Szu-Hsiang Peng ◽  
Wei-Jen Lai ◽  
Ai-Hsien Li ◽  
Ho-Hsian Yen ◽  
...  
Keyword(s):  
Primary Outcome ◽  
The Elderly ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Age Range ◽  
Number Of Passes

Objectives Elderly acute ischemic stroke (AIS) patients (≥80 years) would have dismal clinical outcomes even after successful endovascular revascularization for large vessel occlusion (LVO) in the anterior circulation. We aimed to identify predictors of 30-day mortality after endovascular thrombectomy (EVT) in the elderly. Materials and Methods We included older patients who underwent EVT for AIS due to LVO within 6 h after stroke onset in the anterior circulation between 2017 and 2019. Patients due to posterior circulation stroke, with intracerebral hemorrhage (ICH) or pre-stroke modified Rankin Scale (mRS) score of 4 and 5 were excluded. The primary outcome was mortality within 30 days of EVT. The association between clinical, imaging, procedural, follow-up imaging and mortality were analyzed. Successful reperfusion was defined as modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b or 3. Possible predictors of 30-day mortality were assessed by univariate and multivariable logistic regression. Results Total 238 AIS patients eligible for EVT were identified with 58 patients aged 80 years or more. 48 patients met inclusion criteria. Median age was 86 years (age range, 82–102 years). Successful reperfusion was achieved in 38 (79.2%) patients. The 30-day and 90-day mortality rate were 25% and 33.3%, respectively. The independent predictors of 30-day mortality were collateral scores <3 on mCTA (adjusted OR, 16.571; 95% CI, 1.041–263.868; p = 0.047) and number of passes (adjusted OR, 2.475; 95% CI, 1.047–5.847; p = 0.039). Conclusions Lower collateral scores on mCTA and higher number of passes in thrombectomy were independently predictive of 30-day mortality in the elderly.

scholarly journals Mechanical Thrombectomy of Large Vessel Occlusions in COVID-19 Related Stroke: Endovascular and Clinical Outcomes

2020 ◽  
Author(s):  
Anas S. Al-Smadi ◽  
Srishti Abrol ◽  
Ali Luqman ◽  
Parthasarathi Chamiraju ◽  
Hani Abujudeh
Keyword(s):  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Case Series ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Ischemic Disease ◽  
Patient Demographics

Abstract Background and PurposeStroke is a drastic complication and a poor prognostic marker of COVID-19 disease which emphasizes the importance of early identification and management of this complication. In this case series, we describe our experience of mechanical thrombectomy of large vessel occlusions (LVO) in patients with COVID-19.MethodsWe performed a retrospective study of a series of confirmed COVID-19 patients who underwent endovascular thrombectomy for acute cerebrovascular ischemic disease with large vessel occlusion. Patient demographics, presentations, lab values, angiographic and clinical outcomes were also reviewed.ResultsThree COVID-19 patients with large vessel occlusion who underwent endovascular thrombectomy were identified in our multi-center institution. Two patients had respiratory symptoms prior presentation and one patient presented initially with clinical deficits. Two patients had anterior circulation occlusion in the middle cerebral artery territory vs one had posterior circulation occlusion in the basilar artery. There was good angiographic outcome post thrombectomy in all patients, however poor clinical outcomes noted with no significant improvement in neurological manifestations in comparison with baseline at presentation. All patients developed critically severe symptoms during hospitalization requiring intubation and one patient died of COVID-19 related respiratory failure.ConclusionIn this small case series, we noted worse clinical outcomes in COVID-19 related LVO stroke despite effective thrombectomy, which may be related to the underlying COVID-19 disease and/or the nature of clot in these patients.

Abstract P559: Sex Differences in Clinical Outcomes After Endovascular Thrombectomy for Large Vessel Occlusion Stroke: A Sub-Analysis of the SELECT Study

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Johanna T Fifi ◽  
Thanh Nguyen ◽  
Sarah Song ◽  
Anjail Z Sharrief ◽  
Deep Pujara ◽  
...  
Keyword(s):  
Sex Differences ◽  
Functional Independence ◽  
Large Vessel ◽  
Repeated Measure ◽  
Large Vessel Occlusion ◽  
Post Discharge ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Discharge Disposition

Background: Women have been shown to have greater disability than men after acute ischemic stroke (AIS) treated by thrombolysis. Whether endovascular thrombectomy (EVT) outcomes differ by sex with AIS from large vessel occlusion (LVO) is controversial. We compared sex differences in EVT outcomes and assessed relationship to post-discharge improvement. Methods: In SELECT prospective cohort, EVT treated anterior circulation LVOs (ICA, MCA M1/M2) ≤24 hrs from LKW were stratified by sex. Discharge, 90-day mRS were compared in all patients and a propensity matched cohort. We evaluated mRS improvement (discharge to 90-day) using repeated measure mixed regression with linear approximation of mRS. Results: Of 285 patients, 139 (48.8%) were women, and older (mean IQR 69 years (57,81) vs 65 (56,75), p=0.04) with similar NIHSS (17 (11,22) vs 16 (12,20), p=0.44). Women had smaller perfusion lesion 109 (66,151) vs 154 (104,198) cc, p<0.001) and better collaterals on CTA/CTP but similar ischemic core size 8 (0,25) vs 11 (0,38) cc, p=0.22. Discharge functional independence rates, mean (IQR) mRS were similar (women 39% vs men 46%, p=0.14, and mRS: 3 vs 3, p=0.43). 90-day mRS 0-2 did not differ between women and men (50% vs 55%, aOR 0.77, 95% CI 0.39-1.50, p=0.39) and mean (IQR) mRS: 2 (1,4) vs 2 (0,4). Larger predicted mRS score improvement trend seen in men (2.62 vs 2.21, reduction 0.41) than women (2.65 vs 2.46, reduction: 0.19, p=0.21), Fig 2A. In propensity matched 65 pairs, women exhibited worse 90-day mRS 0-2 (46% vs 60%, aOR 0.41, 95% CI 0.16-1.00, p=0.05). mRS improvement from discharge to 90-day was significantly larger in men (2.49 vs 1.88, reduction 0.61 vs women 2.52 vs 2.44, reduction 0.08, p=0.04), despite similar discharge disposition Fig 2B. Conclusion: Women had similar discharge outcomes as men following EVT, but improvement at 90 days was significantly worse in women. Further exploration of the influence of post-discharge factors to identify target interventions is warranted.

White Matter Hyperintensity Burden and Collateral Circulation in Large Vessel Occlusion Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Imad Derraz ◽  
Mohamed Abdelrady ◽  
Nicolas Gaillard ◽  
Raed Ahmed ◽  
Federico Cagnazzo ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
White Matter ◽  
Acute Ischemic Stroke ◽  
Collateral Circulation ◽  
Large Vessel ◽  
White Matter Hyperintensity ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy

Background and Purpose: White matter hyperintensity (WMH), a marker of chronic cerebral small vessel disease, might impact the recruitment of leptomeningeal collaterals. We aimed to assess whether the WMH burden is associated with collateral circulation in patients treated by endovascular thrombectomy for anterior circulation acute ischemic stroke. Methods: Consecutive acute ischemic stroke due to anterior circulation large vessel occlusion and treated with endovascular thrombectomy from January 2015 to December 2017 were included. WMH volumes (periventricular, deep, and total) were assessed by a semiautomated volumetric analysis on fluid-attenuated inversion recovery–magnetic resonance imaging. Collateral status was graded on baseline catheter angiography using the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grading system (good when ≥3). We investigated associations of WMH burden with collateral status. Results: A total of 302 patients were included (mean age, 69.1±19.4 years; women, 55.6%). Poor collaterals were observed in 49.3% of patients. Median total WMH volume was 3.76 cm 3 (interquartile range, 1.09–11.81 cm 3 ). The regression analyses showed no apparent relationship between WMH burden and the collateral status measured at baseline angiography (adjusted odds ratio, 0.987 [95% CI, 0.971–1.003]; P =0.12). Conclusions: WMH burden exhibits no overt association with collaterals in large vessel occlusive stroke.

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