NCCT and CTA-based imaging protocol for endovascular treatment selection in late presenting or wake-up strokes

IntroductionRecently, the benefit of selecting patients for endovascular treatment (EVT) beyond the 6-hour time window using a tissue-based approach was demonstrated in two randomized trials. The optimal imaging protocol for selecting patients is under debate, and it is still unknown if a simpler and faster protocol may adequately select patients with wake-up stroke (WUS) and late-presenting stroke (LPS) for EVT.ObjectiveTo compare outcomes of patients submitted to EVT presenting within 6 hours of symptom onset or 6–24 hours after last seen well, selected using non-contrast computed tomography (NCCT) and CT angiography (CTA).MethodsAn observational study was performed, which included consecutive patients with anterior circulation ischemic stroke with large vessel occlusion treated with EVT. Patients presenting within 6 hours were treated if their NIH Stroke Scale (NIHSS) score was ≥6 and Alberta Stroke Program Early CT score (ASPECTS) was ≥6, while patients presenting with WUS or 6–24 hours after last seen well (WUS/LPS) were treated if their NIHSSscore was ≥12 and ASPECTS was ≥7.Results249 patients were included, 63 of whom were in the WUS/LPS group. Baseline characteristics were similar between groups, except for longer symptom-recanalization time, lower admission NIHSS (16 vs 17, P=0.038), more frequent tandem occlusions (25.4% vs 11.8%, P=0.010), and large artery atherosclerosis etiology (22.2% vs 11.8%, P=0.043) in the WUS/LPS group. No differences in symptomatic intracranial hemorrhage, peri-procedural complications or mortality were found between groups. Three-month functional independence was similar in both groups (65.1% in WUS/LPS vs 57.0% in ≤6 hours, P=0.259) and no differences were found after adjustment for confounders.ConclusionsThis real-world observational study suggests that EVT may be safe and effective in patients with WUS and LPS selected using clinical-core mismatch (high NIHSS/high ASPECTS in NCCT).

Download Full-text

Abstract TMP11: Endovascular Treatment for Acute Ischemic Stroke in the Within 6-Hour versus 6-24-Hour Window: Simple Imaging Protocol

Stroke ◽

10.1161/str.51.suppl_1.tmp11 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Trung Nguyen ◽

Huong Nguyen ◽

Thanh Nguyen ◽

Triet Ngo ◽

Binh Pham ◽

...

Keyword(s):

Ischemic Stroke ◽

Observational Study ◽

Endovascular Treatment ◽

Real World ◽

Infarct Volume ◽

Functional Independence ◽

Large Artery ◽

Advanced Imaging ◽

Escape Trial ◽

Imaging Protocol

Introduction: DAWN and DEFUSE 3 trials utilized advanced imaging to prove the benefit of endovascular treatment (EVT) in patients within 6-24 hours. There is increasing evidence to suggest the limitations of advanced imaging in real-world practice. Non-contrast-enhanced computed tomography (NCCT) has proved with good sensitivity and specificity in the definition of infarct core. It is still unknown if a simpler and faster protocol may adequately select patients within 6-24 hours for EVT. Hypothesis: To compare outcomes of patients submitted to EVT presenting within 6 hours or 6-24 hours, selected using simple imaging protocol. Methods: An observational study was performed, which included consecutive patients with anterior circulation ischemic stroke eligible for EVT within 6 hours or 6-24 hours. Patients within early window received routine treatment, while patients presenting within late window were treated if they had a mismatch between the clinical deficit, the infarct volume, and collateral blood blow: (NIHSS score was ≥10 and ASPECTS was ≥7) or (ASPECTS was =6, and the collateral score was ≥2). ASPECTS of NCCT/DWI-MRI and collateral status on CTA/DSA were assessed by a blinded neuroradiologist. The collateral grading system was scored on a scale of 0-3 as in the ESCAPE trial. Results: Of the 184 patients were included, 77 (41,8%) received thrombectomy in late window, 107 (58,2%) received acute treatment in early window. Baseline characteristics were similar between groups, except for longer onset to groin puncture time (median, 300 vs 705 min; P<0,0001), higher admission NIHSS (median, 13 vs 16; P<0,0001), lower in ASPECTS (median, 9 vs 8; P<0,0001), and large artery atherosclerosis etiology (61,7 vs 72,7%, P=0,002) in the late window group. No significant differences in successful reperfusion rate and rates of parenchymal hematoma type 2 (81,3 vs 83,1%, P=0,75; 4/107 vs 4/77, P=0,63, respectively). Functional independence (mRS 0-2) and mortality at 90 days did not differ significantly (65,4 vs 57,1%, P=0,25; 10,3 vs 6,5%, P=0,43; respectively). Conclusions: This real-world observational study suggests that EVT may be safe and effective in patients presenting within 6-24 hours selected using clinical-core mismatch and collateral blood blow.

Download Full-text

Thrombectomy 6-24 hours after stroke in trial ineligible patients

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-013915 ◽

2018 ◽

Vol 10 (11) ◽

pp. 1033-1037 ◽

Cited By ~ 28

Author(s):

Shashvat M Desai ◽

Marcelo Rocha ◽

Bradley J Molyneaux ◽

Matthew Starr ◽

Cynthia L Kenmuir ◽

...

Keyword(s):

Time Window ◽

Functional Independence ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Off Label ◽

Symptomatic Intracranial Hemorrhage ◽

Comprehensive Stroke Center ◽

Stroke Center

Background and purposeThe DAWN and DEFUSE-3 trials demonstrated the benefit of endovascular thrombectomy (ET) in late-presenting acute ischemic strokes due to anterior circulation large vessel occlusion (ACLVO). Strict criteria were employed for patient selection. We sought to evaluate the characteristics and outcomes of patients treated outside these trials.MethodsA retrospective review of acute ischemic stroke admissions to a single comprehensive stroke center was performed during the DAWN trial enrollment period (November 2014 to February 2017) to identify all patients presenting in the 6–24 hour time window. These patients were further investigated for trial eligibility, baseline characteristics, treatment, and outcomes.ResultsApproximately 70% (n=142) of the 204 patients presenting 6–24 hours after last known well with NIH Stroke Scale score ≥6 and harboring an ACLVO are DAWN and/or DEFUSE-3 ineligible, most commonly due to large infarct burden (38%). 26% (n=37) of trial ineligible patients with large vessel occlusion strokes received off-label ET and 30% of them achieved functional independence (modified Rankin Scale 0–2) at 90 days. Rates of symptomatic intracranial hemorrhage and mortality were 8% and 24%, respectivelyConclusionTrial ineligible patients with large vessel occlusion strokes receiving off-label ET achieved outcomes comparable to DAWN and DEFUSE-3 eligible patients. Patients aged <80 years are most likely to benefit from ET in this subgroup. These data indicate a larger population of patients who can potentially benefit from ET in the expanded time window if more permissive criteria are applied.

Download Full-text

Abstract P263: Do Different Sites of Vessel Occlusion Dictate the Need for Intubation Prior to Endovascular Treatment and Have an Effect on Outcome?

Stroke ◽

10.1161/str.52.suppl_1.p263 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Ameer E Hassan ◽

Victor M Ringheanu ◽

Raul G Nogueira ◽

Laurie Preston ◽

Adnan I Qureshi ◽

...

Keyword(s):

Endovascular Treatment ◽

Functional Independence ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Number Of Patients ◽

Baseline Characteristics ◽

Comprehensive Stroke Center ◽

Stroke Center ◽

Proven Method ◽

Morbid Conditions

Introduction: Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusion. In order to ensure patients safety prior to and during EVT, preprocedural intubation has been adopted in many centers as a means for airway protection and immobilization. However, the correlation between site of vessel occlusion, need for intubation, and outcomes, has not yet been established. Methods: Through the utilization of a prospectively collected database at a comprehensive stroke center between 2012-2020, demographics, co-morbid conditions, intracerebral hemorrhage, mortality rate, and functional independence outcomes were examined. The outcomes and sites of occlusion between patients receiving mechanical thrombectomy (MT) treated while intubated versus those treated under conscious sedation (CS) were compared. Results: Out of 625 patients treated with MT, a total of 218 (34.9%) were treated while intubated (average age 70.3 ± 13.7, 37.2% women), and 407 (65.1%) were treated while under CS (average age 70.3 ± 13.7, 47.7% women); see Table 1 for baseline characteristics and outcomes. A higher number of patients requiring intubation had an occlusion in the basilar versus those only requiring CS. No differences were noted in regard to the proportion of patients receiving intubation or CS when treated for RMCA, LMCA, or internal carotid artery occlusions. Conclusion: Intubation + MT was associated with significantly worsened outcomes in regard to recanalization rates, functional outcome, and mortality. In anterior circulation strokes, intubation in RMCA patients were found to have poorer clinical outcome. Higher rates of intubation were also found to be needed in patients with basilar occlusions. Further research is required to determine whether site of occlusion dictates the need for intubation, and whether intubation allows for favorable outcome between R and LMCA occlusions.

Download Full-text

Abstract TMP6: Peri-procedural Complications of Endovascular Treatment for Acute Stroke in SWIFT Trial

Stroke ◽

10.1161/str.44.suppl_1.atmp6 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Paul Akins ◽

Arun P Amar ◽

Sean Pakbaz ◽

Jeremy Fields

Keyword(s):

Endovascular Treatment ◽

Rescue Therapy ◽

Detailed Knowledge ◽

Stroke Patients ◽

Vessel Occlusion ◽

Procedural Complications ◽

Symptomatic Intracranial Hemorrhage ◽

Technical Factors ◽

Vessel Dissection ◽

Retrieval Device

Background: Management of patients with ischemic stroke after endovascular treatment requires knowledge of peri-procedural complications. The SWIFT trial compared two devices (Merci and SOLITAIRE) in a randomized, prospective study. We reviewed peri-procedural complications of endovascular treatment and related clinical and technical factors. Methods: The SWIFT database was searched for major peri-procedural complications defined as: symptomatic intracranial hemorrhage (sICH) within 36 hours, symptomatic subarachnoid hemorrhage (SAH), air emboli, vessel dissection, major groin complications, and emboli to new vascular territories. Results: Major peri-procedural complications occurred in 18/144 patients (12.5%) at the following rates: sICH (4.9%); SAH (3.5%), air emboli (1.4%), vessel dissection (4.2%), major groin complications (2.8%), and emboli to new vascular territories (0.7%). We did not observe any statistically significant associations of complications with: age (<65 y 13.8% vs. >65 y 11.6%); type of center (academic 9.3% vs non-academic 13.9%); duration of stroke symptoms (<6h 11.1% vs 14.7% >6 h), NIH stroke scale score (NIHSS<20 12% vs. NIHSS >20,13.9%), iv thrombolytics (no iv tPA 10.5% vs iv tPA15.2%), atrial fibrillation (absent 10.1% vs present 14.7%), site of vessel occlusion (ICA 19.2%; MCA 11.5%); rescue therapy administered after endovascular treatment (no rescue 11.9% vs rescue 14.9%); or device (Merci 14.5%; Solitaire 11.2%). Comparing the Merci to the Solitaire retrieval device, we observed the following peri-procedural events: Conclusion: Detailed knowledge of peri-procedural complications is important for managing stroke patients after endovascular treatment. Fewer endovascular complications were observed after with SOLITAIRE device treatment compared to Merci device treatment, particularly symptomatic cerebral hemorrhage. Device registries will be helpful to gain deeper understanding of rare events.

Download Full-text

Comparisons of ASPECTS 5 and 6 for endovascular treatment in anterior circulation occlusive stroke

Interventional Neuroradiology ◽

10.1177/1591019917720920 ◽

2017 ◽

Vol 23 (5) ◽

pp. 516-520 ◽

Cited By ~ 4

Author(s):

Wenchen Li ◽

Shijun Li ◽

Meifen Dai ◽

Shang Wang ◽

Yunyun Xiong

Keyword(s):

Endovascular Treatment ◽

Functional Outcome ◽

Chinese Patients ◽

Large Artery ◽

Stroke Patients ◽

Anterior Circulation ◽

Future Studies ◽

Good Functional Outcome ◽

Symptomatic Intracerebral Hemorrhage ◽

Symptomatic Intracranial Hemorrhage

Background Whether ASPECTS 5 and ASPECTS 6 were significantly different on clinical outcomes in acute anterior circulation ischemic stroke undergoing endovascular treatment remains unclear. We aimed to retrospectively compare the effectiveness and safety of ASPECTS 5 and ASPECTS 6 in acute anterior circulation large-artery occlusive stroke patients. Methods A total of 41 patients, 14 in the ASPECTS 5 group and 27 in the ASPECTS 6 group, were enrolled between January 2014 and June 2016. Modified Rankin Scale 0–2 was considered as good functional outcome. Symptomatic intracerebral hemorrhage at 72 hours and mortality at 90 days were recorded. Results Good functional outcome at 90 days in the ASPECTS 5 group (0% (0/14)) was significantly lower than that in the ASPECTS 6 group (25.9% (7/27)) ( p = 0.04). Rates of symptomatic intracranial hemorrhage (21.4 (3/14) vs 18.5% (5/27), p = 0.83) and mortality (64.3% (9/14) vs 44.4% (12/27), p = 0.23) within 90 days were not significantly different. There is a trend for a lower rate of successful reperfusion in the ASPECTS 5 group (71.4% (10/14) for ASPECTS 5 vs 92.6% (25/27) for ASPECTS 6, p = 0.07). Conclusions ASPECTS 5 has very little chance to reach good functional outcome in Chinese patients with anterior circulation large-artery occlusive stroke. Future studies with large sample sizes are needed.

Download Full-text

Endovascular Application of Magnetic Resonance Double Mismatch Technique for Acute Anterior Circulation Large Vessel Occlusion with Cerebral Infarction in an Unknown Time Window

Journal of Clinical and Nursing Research ◽

10.26689/jcnr.v4i5.1485 ◽

2020 ◽

Vol 4 (5) ◽

Author(s):

Xiangkong Song ◽

Qing Zhang ◽

Lilin Gao ◽

Jie Qi ◽

Guoqing Wang

Keyword(s):

Magnetic Resonance ◽

Cerebral Infarction ◽

Endovascular Treatment ◽

Time Window ◽

Research Work ◽

Large Vessel ◽

Clinical Effects ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion

Objective: To investigate the clinical effects of applying the magnetic resonance double mismatch technique to endovascular treatment of acute anterior circulation, large vessel occlusion with cerebral infarction in an unknown time window. Methods: The research work was carried out in our hospital, the work was carried out from November 2018 to November 2019, the patients with acute anterior circulation large vessel occlusion with cerebral infarction who were treated in our hospital during this period, 100 patients, 50 patients with an unknown time window and 50 patients with definite time window were selected, and they were named as the experimental and control groups, given different examination methods, were given to investigate the clinical treatment effect. Results: Patients' data on HIHSS score before treatment, the incidence of intracranial hemorrhage and rate of Mrs?2 rating after 90 days of treatment were not significantly different(P>0.05), which was not meaningful. The differences in data between the two groups concerning HIHSS scores were relatively significant before, and after treatment(P<0.05). Conclusion: The magnetic resonance double mismatch technique will be applied in the endovascular treatment of acute anterior circulation large vessel occlusion with cerebral infarction of unknown time window.

Download Full-text

Time to Reset the Definition of Successful Revascularization in Endovascular Treatment of Acute Ischemic Stroke

Cerebrovascular Diseases ◽

10.1159/000491553 ◽

2018 ◽

Vol 46 (1-2) ◽

pp. 40-45 ◽

Cited By ~ 6

Author(s):

Andreia Carvalho ◽

Mariana Rocha ◽

Marta Rodrigues ◽

Tiago Gregório ◽

Henrique Costa ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Independence ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Study Population ◽

Large Heterogeneity ◽

Definition Of ◽

Better Than

Background: A 2013 consensus statement recommended the use of the modified Treatment In Cerebral Ischemia (mTICI) scale to evaluate angiographic revascularization after endovascular treatment (EVT) of acute ischemic stroke due to its higher inter-rater agreement and capacity of clinical outcome prediction. The current definition of successful revascularization includes the achievement of grades mTICI 2b or 3. However, mTICI 2b grade encompasses a large heterogeneity of revascularization states, and prior studies suggested that the magnitude of benefit derived from mTICI 2b and mTICI 3 does not seem to be equivalent. In a way to restrain the referred heterogeneity, Goyal et al. [J Neurointerv Surg 2014; 6: 83–86] proposed a revised mTICI scale that includes a 2c grade (rTICI). Methods: Retrospective analysis of prospectively collected data from consecutive cases of EVT for anterior circulation large-vessel occlusion, performed between January 2015 and July 2017. Patients with mTICI 2b or 3 grades were reclassified according to the rTICI scale, and the outcomes between the 3 revascularization grades (rTICI 2b, 2c, 3) compared. Results: Our study population of 226 patients (64 rTICI 2b, 30 rTICI 2c, 132 rTICI 3) has a mean age of 71 years, 48.2% males, median baseline NIHSS of 16 (13–19) and ASPECTS of 8 (7–9). The 3 revascularization grades are represented by homogeneous populations. Logistic regression analysis showed statistically significant higher rates of functional independence at 3 months (65.9 vs. 50.0%; adjusted OR 0.39, 95% CI 0.18–0.86), with lower rates of mortality (8.3 vs. 15.6%; adjusted OR 3.54, 95% CI 1.14–10.97) and intracranial hemorrhage (ICH) in rTICI 3 than 2b groups. When comparing rTICI 3 with 2c groups, there were only statistically significant differences in the total ICH rate (8.3 vs. 26.7%; adjusted OR 7.08, 95% CI 1.80–27.82) but not in symptomatic ICH. Conclusions: These results corroborate the scarce prior findings suggesting that patients with rTICI 2c grade should be reported separately, since they have similar outcomes to rTICI 3, and better than rTICI 2b patients. Therefore, we suggest resetting the angiographic revascularization endpoint to perfect revascularization (rTICI 2c or 3 grades), a target that neurointerventionalists should strive to achieve.

Download Full-text

Sex-Related Differences in Outcomes After Endovascular Treatment of Patients With Late-Window Stroke

Stroke ◽

10.1161/strokeaha.121.037127 ◽

2022 ◽

Author(s):

Fouzi Bala ◽

Ilaria Casetta ◽

Stefania Nannoni ◽

Darragh Herlihy ◽

Mayank Goyal ◽

...

Keyword(s):

Endovascular Treatment ◽

Scale Score ◽

Intracranial Hemorrhage ◽

Time Window ◽

Intravenous Thrombolysis ◽

Early Time ◽

Functional Independence ◽

Late Time ◽

Individual Patient Level ◽

Symptomatic Intracranial Hemorrhage

Background and Purpose: Sex-related differences exist in many aspects of acute stroke and were mainly investigated in the early time window with conflicting results. However, data regarding sex disparities in late presenters are scarce. Therefore, we sought to investigate differences in outcomes between women and men treated with endovascular treatment in the late time window. Methods: Analyses were based on the SOLSTICE Consortium (Selection of Late-Window Stroke for Thrombectomy by Imaging Collateral Extent), which was an individual-patient level analysis of seven trials and registries. Baseline characteristics, 90-day functional independence (modified Rankin Scale score ≤2), mortality, and symptomatic intracranial hemorrhage were compared between women and men. Effect of sex on the association of age and successful reperfusion (final Thrombolysis in Cerebral Infarction 2b–3) with outcomes was assessed using multivariable logistic regression adjusted for age, National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, time from onset to puncture, occlusion location, intravenous thrombolysis, and successful reperfusion, with interaction terms. Results: Among 608 patients treated with endovascular treatment, 50.5% were women. Women were older than men (median age of 72 versus 68 years, P =0.02) and had a lower prevalence of tandem occlusions (14.0% versus 22.9%, P =0.005). Workflow times were similar between sexes. Adjusted outcomes did not differ between women and men. Functional independence at 90 days was achieved by 127 out of 292 women (43.5%) and 135 out of 291 men (46.4%). Mortality at 90 days (54 [18.5%] versus 48 [16.5%]) and symptomatic intracranial hemorrhage (37 [13.3%] versus 33 [11.6%]) were similar between women and men. There was no sex-by-age interaction on functional outcomes. However, men had higher likelihood of mortality ( P interaction =0.003) and symptomatic intracranial hemorrhage ( P interaction =0.017) with advancing age. Sex did not influence the relation between successful reperfusion and outcomes. Conclusions: In this multicenter analysis of late patients treated with endovascular treatment, sex was not associated with functional outcome. However, sex influenced the association between age and safety outcomes, with men experiencing worse outcomes with advancing age.

Download Full-text

Safety and Outcomes of Thrombectomy in Ischemic Stroke With vs Without Intravenous Thrombolysis

Neurology ◽

10.1212/wnl.0000000000012327 ◽

2021 ◽

pp. 10.1212/WNL.0000000000012327

Author(s):

Niaz Ahmed ◽

Michael Mazya ◽

Ana Paiva Nunes ◽

Tiago Moreira ◽

Jyrki P. Ollikainen ◽

...

Keyword(s):

Cerebral Artery ◽

Intravenous Thrombolysis ◽

Functional Independence ◽

Artery Occlusion ◽

Large Artery ◽

Anterior Circulation ◽

Stroke Disability ◽

Artery First ◽

Symptomatic Intracranial Hemorrhage ◽

Residual Confounding

Objective:To test the hypothesis that intravenous thrombolysis (IVT) treatment prior to endovascular thrombectomy (EVT) is associated with better outcomes in patients with anterior circulation large artery occlusion (LAO) stroke, we examined a large real-world database, the SITS-International Stroke Thrombectomy Register (SITS-ISTR).Methods:We identified centers recording ≥10 consecutive patients in the SITS-ISTR, with at least 70% available modified Rankin Scale (mRS) scores at 3 months during 2014-19. We defined LAO as intracranial internal carotid artery, first and second segment of middle cerebral artery and first segment of anterior cerebral artery. Main outcomes were functional independence (mRS 0-2) and death at 3 months and symptomatic intracranial hemorrhage (SICH) per modified SITS-MOST. We performed propensity score matched (PSM) and multivariable logistic regression analyses.Results:Of 6350 patients from 42 centers, 3944 (62.1%) received IVT. IVT+EVT treated patients had less frequent atrial fibrillation, ongoing anticoagulation, previous stroke, heart failure and pre-stroke disability. PSM analysis showed that IVT+EVT patients had a higher rate of functional independence than EVT alone patients (46.4% vs. 40.3%, p<0.001) and a lower rate of death at 3 months (20.3% vs. 23.3%, p=0.035). SICH rates (3.5% vs. 3.0%, p= 0.42) were similar in both groups. Multivariate adjustment yielded results consistent with PSM.Interpretation:Pretreatment with IVT was associated with favorable outcomes in EVT-treated LAO stroke in the SITS Thrombectomy Registry. These findings, while indicative of international routine clinical practice, are limited by observational design, unmeasured confounding and possible residual confounding by indication.Classification of Evidence:This study provides Class II evidence that IVT prior to EVT increases the probability of functional independence at 3 months compared to EVT alone.

Download Full-text