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

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.

Download Full-text

Impact of ASPECTS on computed tomography angiography source images on outcome after thrombolysis or endovascular therapy in large vessel occlusions

European Journal of Neurology ◽

10.1111/ene.13068 ◽

2016 ◽

Vol 23 (11) ◽

pp. 1599-1605 ◽

Cited By ~ 9

Author(s):

K. Wasser ◽

P. Papanagiotou ◽

F. Brunner ◽

H. Hildebrandt ◽

M. Winterhalter ◽

...

Keyword(s):

Computed Tomography ◽

Endovascular Therapy ◽

Computed Tomography Angiography ◽

Large Vessel

Download Full-text

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

Stroke ◽

10.1161/strokeaha.119.028626 ◽

2020 ◽

Vol 51 (5) ◽

pp. 1613-1615 ◽

Cited By ~ 3

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.

Download Full-text

Systematic evaluation of computed tomography angiography collateral scores for estimation of long-term outcome after mechanical thrombectomy in acute ischaemic stroke

The Neuroradiology Journal ◽

10.1177/1971400919847182 ◽

2019 ◽

Vol 32 (4) ◽

pp. 277-286 ◽

Cited By ~ 3

Author(s):

Daniel Weiss ◽

Bastian Kraus ◽

Christian Rubbert ◽

Marius Kaschner ◽

Sebastian Jander ◽

...

Keyword(s):

Computed Tomography ◽

Computed Tomography Angiography ◽

Cerebral Blood Volume ◽

Mechanical Thrombectomy ◽

Favourable Outcome ◽

Index Score ◽

Modified Rankin Scale ◽

Rater Reliability ◽

Endovascular Thrombectomy ◽

Computed Tomography Perfusion

Purpose This study compares computed tomography angiography-based collateral scoring systems in regard to their inter-rater reliability and potential to predict functional outcome after endovascular thrombectomy, and relates them to parenchymal perfusion as measured by computed tomography perfusion. Methods Eighty-four patients undergoing endovascular thrombectomy in anterior circulation ischaemic stroke were enrolled. Modified Tan Score, Miteff Score, Maas Score and Opercular Index Score ratio were assessed in pre-interventional computed tomography angiographies independently by two readers. Collateral scores were tested for inter-rater reliability by weighted-kappa, for correlations with three-months modified Rankin Scale, and their potential to differentiate between patients with favourable (modified Rankin Scale ≤2) and poor outcome (modified Rankin Scale ≥3). Correlations with relative cerebral blood volume and relative cerebral blood flow were tested in patients with available computed tomography perfusion. Results Very good inter-rater reliability was found for Modified Tan, Miteff and Opercular Index Score ratio, and substantial reliability for Maas. There were no significant correlations between collateral scores and three-months modified Rankin Scale, but significant group differences between patients with favourable and poor outcome for Maas, Miteff and Opercular Index Score ratio. Miteff and Maas were significant predictors of favourable outcome in binary logistic regression analysis. Miteff best differentiated between both outcome groups in receiver-operating characteristics, and Maas reached highest sensitivity for favourable outcome prediction of 96%. All collateral scores significantly correlated with mean relative cerebral blood volume and relative cerebral blood flow. Conclusions Computed tomography angiography scores are valuable in estimating functional outcome after mechanical thrombectomy and reliable across readers. The more complex scores, Maas and Miteff, show the best performances in predicting favourable outcome.

Download Full-text

Effect of Glucocorticoid Treatment on Computed Tomography Angiography Detected Large-Vessel Inflammation in Giant-Cell Arteritis. A Prospective, Longitudinal Study

Medicine ◽

10.1097/md.0000000000000486 ◽

2015 ◽

Vol 94 (5) ◽

pp. e486 ◽

Cited By ~ 45

Author(s):

Sergio Prieto-González ◽

Ana García-Martínez ◽

Itziar Tavera-Bahillo ◽

José Hernández-Rodríguez ◽

José Gutiérrez-Chacoff ◽

...

Keyword(s):

Computed Tomography ◽

Longitudinal Study ◽

Giant Cell Arteritis ◽

Giant Cell ◽

Computed Tomography Angiography ◽

Large Vessel ◽

Glucocorticoid Treatment ◽

Prospective Longitudinal Study ◽

Prospective Longitudinal

Download Full-text

Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.121.000115 ◽

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.

Download Full-text

Improving the Evaluation of Collateral Circulation by Multiphase Computed Tomography Angiography in Acute Stroke Patients Treated with Endovascular Reperfusion Therapies

Interventional Neurology ◽

10.1159/000448525 ◽

2016 ◽

Vol 5 (3-4) ◽

pp. 209-217 ◽

Cited By ~ 24

Author(s):

Alvaro García-Tornel ◽

Vanessa Carvalho ◽

Sandra Boned ◽

Alan Flores ◽

David Rodríguez-Luna ◽

...

Keyword(s):

Computed Tomography ◽

Acute Stroke ◽

Computed Tomography Angiography ◽

Collateral Circulation ◽

Infarct Volume ◽

National Institutes Of Health ◽

Stroke Patients ◽

Endovascular Thrombectomy ◽

The Mean ◽

Mean Time

Good collateral circulation (CC) is associated with favorable outcomes in acute stroke, but the best technique to evaluate collaterals is controversial. Single-phase computed tomography angiography (sCTA) is widely used but lacks temporal resolution. We aim to compare CC evaluation by sCTA and multiphase CTA (mCTA) as predictors of outcome in endovascular treated patients. Methods: Consecutive endovascular treated patients with M1 middle cerebral artery (MCA) or terminal intracranial carotid artery (TICA) occlusion confirmed by sCTA were included. Two more CTA acquisitions with 8- and 16-second delays were performed for mCTA. Endovascular thrombectomy was performed independently of the CC status according to a local protocol [Alberta Stroke Program Early CT score (ASPECTS) >6, modified Rankin scale (mRS) score <3]. CC on sCTA and mCTA were compared. Results: 108 patients were included. Their mean age was 69.6 ± 13 years and their median National Institutes of Health Stroke Scale (NIHSS) score was 17 (interquartile range 8). 79 (73.1%) had M1 MCA and 29 (26.9%) TICA occlusions. The mean time from symptom onset to CTA was 146.8 ± 96.5 min. On sCTA, 50.9% patients presented good CC vs. 57.5% on mCTA. Good CC status in both sCTA and mCTA had a lower 24-hour infarct volume (27.4 vs. 74.8 cm3 on sCTA, p = 0.04; 17.2 vs. 97.8 cm3 on mCTA, p < 0.01). However, only good CC on mCTA was associated with lower 24-hour (5 vs. 8.5, p = 0.04) and median discharge NIHSS (2 vs. 4.5, p = 0.04) scores and functional independency (mRS score <3) at 3 months (76.9 vs. 23.1%, p < 0.01). In a logistic regression model including age, NIHSS, ASPECTS and recanalization, only age (OR 0.96, 95% CI 0.93-0.99, p = 0.02) and good CC on mCTA (OR 5, 95% CI 1.99-12.6, p < 0.01) were independent predictors of functional outcome at 3 months. Conclusion: CC evaluation by mCTA is a better prognostic marker than CC evaluation by sCTA for clinical and functional endpoints in acute stroke patients treated with endovascular thrombectomy.

Download Full-text