O-004 Endovascular therapy in large infarct core strokes: a subgroup analysis of the trevo registry

Purpose: There have been conflicting reports on the correlation between neurological and functional recoveries in acute ischemic stroke. NIHSS and mRS scores not always correlated in patients after treatment. Since the inconsistencies could be related to the variable effectiveness of treatments, the aim of this study was to test their correlation in patients with large vessel proximal occlusion who are eligible but not treated with endovascular therapy. In addition, we analyzed the data based on trichotomized ASPECTS scores to minimize the confounding influence of the infarct core. Methods: The FIRST Trial is a prospective natural history study of a stroke cohort eligible for but untreated by endovascular therapy and ineligible or refractory to IV rtPA. NIHSS and mRS scores were measured in 93 patients at admission, 24 hour and 7 days after hospital presentation and were analyzed by logistic regression against different core infarct volume as indexed by ASPECTS scores of 8-10, 5-7, and 0-4. Results: Median admission NIHSS score was 18 (IQR 14-23, N=93). The mean and mean increase at 24 h NIHSS both showed correlations with trichotomized ASPECTS, p=0.0064 and 0.0202, respectively. NIHSS at 24 h and 7 days displayed a strong relationship with 90 day mRS 0-2 (p=0.0002, N=67; p=0.0003, N=66). NIHSS had a strong correlation to 90 day mRS scores (continuous), with high 7 day scores correlated with high mRS scores and 7 day NIHSS change negatively correlated to 90 day mRS scores (Spearman correlations, all p<0.0001). Significant correlations were seen between 24 h and 7 day NIHSS and 90 day mRS by trichotomized ASPECTS (both p=0.04275). In addition, controlling for trichotomous ASPECTS groups, 7 Day NIHSS score was the best predictor of mRS 90d 0-2 (OR= 0.717, p= 0.0018). Conclusion: These data indicate that there is a strong correlation between neurological and functional recoveries in the natural history of acute ischemic when the confounding influences of treatment and the infarct core are taken into account.

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Abstract 2546: Correlation Between Diffusion-weighted Imaging (DWI) Lesion Volume And Alberta Stroke Program Early CT Score (ASPECTS) In Patients Undergoing Acute Stroke Intervention

Stroke ◽

10.1161/str.43.suppl_1.a2546 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Ashutosh P Jadhav ◽

Mouhammad Jumaa ◽

Sayed Zaidi ◽

Carlos L Salinas ◽

Guangming Zhu ◽

...

Keyword(s):

Acute Stroke ◽

Ct Scan ◽

Endovascular Therapy ◽

Infarct Volume ◽

Medical Center ◽

Lesion Volume ◽

Infarct Core ◽

Mri Scan ◽

Occlusion Time ◽

Software Analysis

Background and Purpose: Selection of patients for endovascular acute stroke therapy is evolving into imaging based paradigms that quantitatively assess infarct core thresholds beyond which reperfusion is considered futile or detrimental. We sought to determine whether a correlation exists between pre-intervention infarct volume as measured by DWI MRI and ASPECT scores on CT in patients with acute stroke treated with endovascular therapy who underwent both a pre-procedure MRI scan and a non-contrast CT scan at our institution. Methods: Retrospective review of a prospectively maintained database of acute ischemic strokes treated with endovascular therapy at the University of Pittsburgh Medical Center during 2004-2011. CT-ASPECT scores were prospectively scored by blinded observers. Infarct volume on DWI was determined by automated software analysis (RAPID, n=25 and MIPAV, n=53). The following additional factors were considered: age, NIHSS, time from last seen well (TLSW) to angiography, site of clot occlusion, time between obtaining CT scan and MRI, and parenchymal hematoma (PH) formation. Results: Of 77 patients included in the study, there was a significant negative correlation between CT-ASPECT score and DWI volume size (p<0.0001, by ANOVA). Table 1 outlines the distribution of ASPECTS scores and corresponding mean DWI volumes along with other variables of interest. The mean time between obtaining the CT and MRI scan was 207 minutes. Conclusions: A CT-ASPECT score of 7 or greater corresponds to an average DWI volume of 23 ml or less. Recent studies have shown that a pre treatment DWI volume of <25 ml is predictive of favorable outcomes. Therefore, our findings provide further support of the concept that an ASPECT score cut off of 7 or greater corresponds to core volume thresholds that are predictive of good outcomes following revascularization. Future prospective studies are needed to compare the benefit of CT ASPECTS scores alone versus DWI MRI or other advanced imaging modalities as selection tool for acute stroke endovascular therapy.

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Thrombectomy for Patients With Large Infarct Core in Practice: Where Should the Pendulum Swing?

Stroke ◽

10.1161/strokeaha.121.034754 ◽

2021 ◽

Author(s):

Thabele M. Leslie-Mazwi ◽

Dorothea Altschul ◽

Claus Z. Simonsen

Keyword(s):

Infarct Core ◽

Pendulum Swing ◽

Large Infarct

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Abstract 127: Predictors of Good Functional Outcomes in an Acute Ischemic Stroke Cohort with a Large Infarct Core Treated with Mechanical Thrombectomy: Signals to Treat?

Stroke ◽

10.1161/str.48.suppl_1.127 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Jeffrey Wagner ◽

Donald Frei ◽

Raul Nogueira ◽

Adnan Siddiqui ◽

Osama O Zaidat ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Outcomes ◽

Mechanical Thrombectomy ◽

Infarct Volume ◽

Target Vessel ◽

Infarct Core ◽

Nihss Score ◽

Good Outcome ◽

Large Infarct

Purpose: Mechanical thrombectomy has been demonstrated to provide benefits in the treatment of acute ischemic stroke (AIS). But whether to treat AIS patients with a large infarct core remains controversial. Although it is a common practice that patients with large infarct core are not offered endovascular treatment, previous data have consistently shown a proportion of these patients may benefit from IA intervention. The purpose of this study is to identify predictors of good outcomes in an AIS cohort with a large infarct volume previously treated with mechanical thrombectomy. Hypothesis: We hypothesize that among AIS patients with a large infarct volume, younger patients (≤66 years) who present with lower NIHSS scores will show good functional outcomes (mRS 0-2) at 90 days if treated with mechanical thrombectomy. Methods: Univariable and multivariable analyses were preformed to identify factors that predict good functional outcomes in AIS patients with ASPECTS 0-5 who were treated with the Penumbra System. Five previous prospective, multicenter trials (PIVOTAL, PICS, RetroSTART, START, SEPARATOR 3D) were included in this study. Patients who presented with symptoms of AIS were analyzed for association between presenting demographics and modified Rankin scale (mRS) score at 90 days in univariate and multivariate analyses. Results: Data for 614 patients with a median age of 69 years and an NIHSS score of 18 met study criteria. Of these, the 90-day mRS 0-2 rate and mortality were, respectively, 40.23% and 25.41%. Among those with ASPECTS 0-5 (N=93), 17.20% had good functional outcome. An age of ≤66 years was significantly associated with good outcome (p<0.0001) among those with ASPECTS 0-5. Within this age group who had ASPECTS 0-5, a baseline NIHSS score of ≤ 20 (p= 0.0088) with a target vessel location at the MCA (p=0.0210) were also strong predictors of good outcome if treated by mechanical thrombectomy. Conclusion: These data demonstrate that age ≤66 years, baseline NIHSS score of ≤ 20 with a target vessel location in the MCA are important predictors of good outcomes in an AIS cohort with a large infarct core who are eligible for mechanical thrombectomy.

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Abstract 4: Excellent Collaterals in STAR: Minimal Infarct Core Trumps the Degree of Hypoperfusion

Stroke ◽

10.1161/str.45.suppl_1.4 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

David S Liebeskind ◽

Fabien Scalzo ◽

Mark S Johnson ◽

Antoni Dávalos ◽

Alain Bonafé ◽

...

Keyword(s):

Endovascular Therapy ◽

Perfusion Imaging ◽

Mr Perfusion ◽

Infarct Core ◽

Age And Gender ◽

Mr Perfusion Imaging ◽

Potent Predictor ◽

Flow Restoration ◽

Grade 3 ◽

And Gender

Background: Collateral grade on DSA before acute endovascular therapy of stroke predicts revascularization. Excellent collaterals were a potent predictor of good clinical outcomes at 90 days after treatment in Solitaire Flow Restoration Thrombectomy for Acute Revascularization (STAR). We studied whether excellent collaterals could be detected with either CT or MR perfusion imaging acquired immediately before treatment. Methods: Independent angio and CT/MRI core labs analyzed baseline DSA ASITN/SIR collateral grade and CT/MR perfusion imaging volumes (equivalent definitions of infarct core and Tmax > 4, 6, 8, 10, 12, 14 s). Hypoperfusion was defined as Tmax > 6s, with Tmax hypoperfusion intensity ratios of 10/6 and 14/6, and target and malignant profiles based on DEFUSE-2. Excellent collateral grade (3-4) was analyzed by pretreatment CT/MRI patterns. Results: 64 of 202 cases in STAR (mean age 67.9 ± 13.1 years; 53% women; median baseline NIHSS 15 (8-25)) had CT/MR perfusion volumes and ASITN/SIR collateral grade analyzed. Distribution of collateral grade (0, n=2; 1, n=31; 2, n=14; 3, n=15; 4, n=2) was similar to the entire STAR population. Excellent collaterals were unrelated to age and gender, with a trend towards lower NIHSS (OR 0.9, p=0.12). Excellent collaterals in 17/64 (27%) demonstrated very small core volumes (0 cc, n=8; 1-25 cc, n=8; > 25 cc, n=1) compared to other cases. Similarly, clinical-core mismatch (defined as baseline NIHSS ≥8-16 and core ≤ 25 cc; baseline NIHSS ≥17 and ≤ 50 cc) was noted in 16/17 (94%). The extent of hypoperfusion (Tmax > 6s) and degrees of hypoperfusion (Tmax 4-14, 10/6, and 14/6) were not related to the presence of excellent collaterals. Target mismatch (n=53/64, 83%) showed an OR 4.32 (p=0.18) for excellent collaterals and no malignant profiles were associated with grade 3-4. Conclusions: CT/MR perfusion patterns prior to endovascular therapy are associated with excellent collaterals, evident as very small infarct core, target mismatch, and clinical-core mismatch. The degree of Tmax hypoperfusion severity alone cannot be used to identify presence of excellent collaterals.

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Role of Neuroimaging in Guiding Treatment Decisions on Endovascular Thrombectomy

Neurology International Open ◽

10.1055/s-0043-102381 ◽

2017 ◽

Vol 01 (01) ◽

pp. E18-E27

Author(s):

Daniel Kaiser ◽

Johannes Gerber ◽

Volker Puetz

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Vascular Occlusion ◽

Artery Occlusion ◽

Infarct Core ◽

Endovascular Thrombectomy ◽

Non Invasive ◽

Cerebral Artery Occlusion

AbstractSix recent randomized controlled trials showed a significant benefit of endovascular therapy on patient outcome in acute ischemic stroke due to anterior cerebral artery occlusion. The positive results of these trials need to be implemented in clinical routine. Suitable patients should be evaluated for thrombectomy reliably and fast. All trials confirmed the role of pretherapeutic neuroimaging as crucial in selecting patients who can benefit from endovascular therapy. However, different approaches have been used, including imaging of the target vascular occlusion, infarct core, arterial collateral supply or the penumbra. In this review we discuss, in the context of the recent trials, the different methods of non-invasive neuroimaging and their role in decision-making for thrombectomy in acute ischemic stroke.

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Abstract W P8: Role of Core Infarct Volume Affecting the Number Needed to Treat in Endovascular Therapy for Acute Ischemic Stroke From Large Vessel Occlusion

Stroke ◽

10.1161/str.45.suppl_1.wp8 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Osama O Zaidat ◽

Albert Yoo ◽

Vallabh Janardhan ◽

Don Frei ◽

Lynne Ammar ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Functional Status ◽

Endovascular Therapy ◽

Treatment Effect ◽

Large Vessel ◽

Infarct Core ◽

Number Of Patients ◽

The Impact

Purpose: The infarct core has been hypothesized to be highly predictive of treatment effect for endovascular intervention in acute ischemic stroke from large vessel proximal occlusion. The purpose of this study was to determine how it affects the number of patients needed to treat (NNT) by this therapy to improve long term functional status. Methods: Patients with acute stroke not eligible and/or refractory to IV rtPA, treated by the Penumbra System (N=463) were pooled from various studies: Pivotal (N=83), PICS (N=174), RetroSTART (N=96) and START (N=110). They were compared with 62 control patients who were eligible for but not treated by endovascular therapy. The NNT for both groups to achieve 90 day functional independence as defined by an mRS score of ≤2 were compared. The impact of the infarct core at presentation defined by ASPECTS trichotomized as small (8-10), medium (5-7) and large (0-4) was assessed. The distribution of the infarct core (N) for Penumbra:control patients were: 257:50, 155:7 and 51:3, respectively for small, medium and large. Two control patients did not have ASPECTS scores. Results: There were no differences in baseline characteristics between the two group median values (Control;Penumbra): Age (72;68), NIHSS (18;17), ASPECTS (ASP) (9;8). There were significant differences in rate of recanalization, all-cause mortality and good functional outcome (mRS ≤2) but not symptomatic ICH (Table). The NNT to improve functional status was 5.6 for the entire cohort of treated patients, 4.7 for those with small core, 4.1 for medium and 12.8 for large. Conclusion: These data indicate that endovascular treatment may not be effective in patients with a large infarct core and could contribute to the high NNT needed to achieve long term good functional status. Eliminating this group at time of triage may significantly lower the NNT and improve the treatment effect of this therapy.

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