Interaction between time, ASPECTS, and clinical mismatch

BackgroundImaging-based patient selection for neurothrombectomy is reliant on the identification of irreversibly damaged brain tissue (core) and salvageable tissue (penumbra). The DAWN trial used the clinical-core mismatch (CCM) paradigm (clinical deficit out of proportion to infarct volume). We aim to determine the prevalence of CCM in large vessel occlusion (LVO) strokes and study the impact of time and the Alberta Stroke Program Early CT Score (ASPECTS) on the likelihood of mismatch.MethodsWe performed a retrospective observational analysis of internal carotid artery/middle cerebral artery M1 occlusions with available advanced imaging (relative cerebral blood flow/MRI). We used automated software for infarct volume analysis and ASPECTS determination. The prevalence of CCM and the impact of time and ASPECTS were analyzed.ResultOne hundred and eighty-five LVO strokes were included. Mean age was 71±15 years and median National Institutes of Health Stroke Scale score was 17 (range 12–21). Mean ischemic core volume was 50±69 mL. Within 0–24 hours, CCM was present in 53% and ranged from 63% in 0–3 hours to 25% at 21–24 hours (p=0.03). Prevalence of mismatch reduced 1.6% for every 1 hour increase in time to imaging. CCM prevalence by ASPECTS groups was: ASPECTS 9–10: 77%, ASPECTS 6–8: 65%, ASPECTS 0–5: 13% (p<0.01), with a 6.4% decrement for every 1 point decrease in ASPECTS. The prevalence of mismatch did not diminish over time among ASPECTS groups and higher ASPECTS was an independent predictor of CCM (OR 1.4 (95% CI 1.1 to 1.7), p<0.001).ConclusionsCCM is present in 57% and 50% of LVO strokes in the 0–6 and 6–24 hour window, respectively. The prevalence of mismatch declines with increasing time (1.6%/hour) and decreasing ASPECTS (6.4%/point). Among ASPECTS groups the prevalence of mismatch does not decline over time. These data support the use of an ASPECTS-based paradigm for late window patient selection.

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Abstract TP77: Impact of Time and Aspects on Clinical Core Mismatch in Large Vessel Occlusion Strokes

Stroke ◽

10.1161/str.51.suppl_1.tp77 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Shashvat Desai ◽

Bradley J Molyneaux ◽

Marcelo Rocha ◽

Matthew Starr ◽

Tudor G Jovin ◽

...

Keyword(s):

Patient Selection ◽

Time Window ◽

Ct Perfusion ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Ct Head ◽

Ischemic Core ◽

The Impact ◽

Core Volume

Introduction: Patient selection for endovascular thrombectomy (EVT) for anterior circulation large vessel occlusion (LVO) strokes in the 6-24-hour time window is dependent on delineating clinical core mismatch (CCM) as defined by DAWN trial criteria. In contrast, patient selection in the early window (0-6 hours) can be performed using ASPECTS on CT head. We aim to determine the prevalence of DAWN-CCM in LVO strokes and the impact of time and ASPECTS. Methods: Retrospective analysis of large vessel occlusion [internal carotid and middle cerebral artery-M1] strokes at a CSC. Consecutive patients who underwent CT perfusion or MRI within 120 minutes of CT head were included in the study (treated and untreated). Ischemic core volume was assessed using RAPID [IschemaView] and ASPECTS using automated ASPECTS [Brainomix]. CCM was defined using DAWN trial criteria [DAWN-CCM: NIHSS ≥10 and core <31 ml, NIHSS ≥20 and core <51 ml]. Results: A total of 116 patients were included. Mean age was 71 ±14 and 62% were females. Mean ischemic core volume and median ASPECTS were 46 ±65 ml and 8 (6-9), respectively. In patients with NIHSS score ≥10 (98), 57% had DAWN-CCM in the 0-24-hour window. Proportion of patients with DAWN-CCM in 6-24-hour window was 70% (6-12 hours), 50% (12-18 hours), and 50% (18-24 hours) [p=0.35]. Proportion of patients with DAWN-CCM by ASPECTS group was 88% (ASPECTS 9-10), 64% (ASPECTS 6-8) and 13% (ASPECTS 0-5) [p=<0.01] (Figure 1). Probability of DAWN-CCM declines by 7% for every 2 hours increase in TLKW to imaging, and by 13% for every 1-point decrease in ASPECTS. Conclusion: Approximately 57% of LVO strokes have clinical core mismatch. LVO strokes with DAWN-CCM decline with increasing time and decreasing ASPECTS. ASPECTS alone may be sufficient to identify patients with DAWN-CCM in a resource limited setting and avoid time consuming advanced imaging.

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Utility of CT perfusion scanning in patient selection for acute stroke intervention: experience at University at Buffalo Neurosurgery–Millard Fillmore Gates Circle Hospital

Neurosurgical FOCUS ◽

10.3171/2011.2.focus1130 ◽

2011 ◽

Vol 30 (6) ◽

pp. E4 ◽

Cited By ~ 6

Author(s):

Peter T. Kan ◽

Kenneth V. Snyder ◽

Parham Yashar ◽

Adnan H. Siddiqui ◽

L. Nelson Hopkins ◽

...

Keyword(s):

Acute Stroke ◽

Patient Selection ◽

Ct Perfusion ◽

Brain Parenchyma ◽

National Institutes Of Health ◽

Time Interval ◽

Case Examples ◽

Flow Parameters ◽

Selection For ◽

The Brain

Computed tomography perfusion scanning generates physiological flow parameters of the brain parenchyma, allowing differentiation of ischemic penumbra and core infarct. Perfusion maps, along with the National Institutes of Health Stroke Scale score, are used as the bases for endovascular stroke intervention at the authors' institute, regardless of the time interval from stroke onset. With case examples, the authors illustrate their perfusion-based imaging guidelines in patient selection for endovascular treatment in the setting of acute stroke.

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Comparing the Prognostic Impact of Age and Baseline National Institutes of Health Stroke Scale in Acute Stroke due to Large Vessel Occlusion

Stroke ◽

10.1161/strokeaha.120.032364 ◽

2021 ◽

Author(s):

Johanna Maria Ospel ◽

Scott Brown ◽

Manon Kappelhof ◽

Wim van Zwam ◽

Tudor Jovin ◽

...

Keyword(s):

Effect Size ◽

Interquartile Range ◽

National Institutes Of Health ◽

Large Vessel ◽

Prognostic Impact ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Good Outcome ◽

The Impact ◽

Size Estimates

Background and Purpose: Little is known about the combined effect of age and National Institutes of Health Stroke Scale (NIHSS) in endovascular treatment (EVT) for acute ischemic stroke due to large vessel occlusion, and it is not clear how the effects of baseline age and NIHSS on outcome compare to each other. The previously described Stroke Prognostication Using Age and NIHSS (SPAN) index adds up NIHSS and age to a 1:1 combined prognostic index. We added a weighting factor to the NIHSS/age SPAN index to compare the relative prognostic impact of NIHSS and age and assessed EVT effect based on weighted age and NIHSS. Methods: We performed adjusted logistic regression with good outcome (90-day modified Rankin Scale score 0–2) as primary outcome. From this model, the coefficients for NIHSS and age were obtained. The ratio between the NIHSS and age coefficients was calculated to determine a weighted SPAN index. We obtained adjusted effect size estimates for EVT in patient subgroups defined by weighted SPAN increments of 3, to evaluate potential changes in treatment effect. Results: We included 1750/1766 patients from the HERMES collaboration (Highly Effective Reperfusion Using Multiple Endovascular Devices) with available age and NIHSS data. Median NIHSS was 17 (interquartile range, 13–21), and median age was 68 (interquartile range, 57–76). Good outcome was achieved by 682/1743 (39%) patients. The NIHSS/age effect coefficient ratio was ([−0.0032]/[−0.111])=3.4, which was rounded to 3, resulting in a weighted SPAN index defined as ([3×NIHSS]+age). Cumulative EVT effect size estimates across weighted SPAN subgroups consistently favored EVT, with a number needed to treat ranging from 5.3 to 8.7. Conclusions: The impact on chance of good outcome of a 1-point increase in NIHSS roughly corresponded to a 3-year increase in patient age. EVT was beneficial across all weighted age/NIHSS subgroups.

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Abstract TP74: Aspects Scoring Applied to CTA Source Images is Predictive of Final Infarct Volume and Good Functional Outcome

Stroke ◽

10.1161/str.51.suppl_1.tp74 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Joseph F Carrera ◽

Joseph H Donahue ◽

Prem P Batchala ◽

Andrew M Southerland ◽

Bradford B Worrall

Keyword(s):

Linear Regression ◽

Functional Outcome ◽

Infarct Volume ◽

Univariate Analysis ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Good Outcome ◽

The Impact

Introduction: CTP and MRI are increasingly used to assess endovascular thrombectomy (EVT) candidacy in large vessel occlusion stroke. Unfortunately, availability of these advanced neuroimaging techniques is not widespread and this can lead to over-triage to EVT-capable centers. Hypothesis: ASPECTS scoring applied to computed tomography angiography source images (CTA-SI) will be predictive of final infarct volume (FIV) and functional outcome. Methods: We reviewed data from consecutive patients undergoing EVT at our institution for anterior circulation occlusion between 01/14 - 01/19. We recorded demographics, comorbidities, NIHSS, treatment time parameters, and outcomes as defined by mRS (0-2 = good outcome). Cerebrovascular images were assessed by outcome-blinded raters and collateral score, TICI score, FIV, and both CT and CTA-SI ASPECTS scores were noted. Patients were grouped by ASPECTS score into low (0-4), intermediate (5-7), and high (8-10) for some analyses. FIV was predicted using a linear regression with NIHSS, good reperfusion (TICI 2b/3), collateral score, CT to groin puncture, CT and CTA-SI ASPECTS as independent variables. After excluding those with baseline mRS≥2, a binary logistic regression was performed including covariates of age, NIHSS, good reperfusion, and diabetes (factors significant at p<0.05 on univariate analysis) to assess the impact of CTA-SI ASPECTS group on outcome. Results: Analysis included 137 patients for FIV and 102 for outcome analysis (35 excluded for baseline mRS≥ 2). Linear regression found CTA-SI ASPECTS (Beta -10.8, p=0.002), collateral score (Beta -42.9, p=0.001) and good reperfusion (Beta 72.605, p=0.000) were independent predictors of FIV. Relative to the low CTA-SI ASPECTS group, the high CTA-SI ASPECTS group was more likely to have good outcome (OR 3.75 [95% CI 1.05-13.3]; p=0.41). CT ASPECTS was not predictive of FIV or good outcome. Outcomes: In those undergoing EVT for anterior circulation occlusion, CTA-SI ASPECTS is predictive of both FIV and functional outcome, while CT ASPECTS predicts neither. CTA-SI ASPECTS holds promise as a lower-cost, more widely available option for triage of patients with large vessel occlusion. Further study is needed comparing CTA-SI ASPECTS to CTP parameters.

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Abstract P362: A Volumetric Comparison of Computed Tomography Perfusion Rapid Core Volume in Different Time Frames With Diffusion-Weighted Imaging Infarct Volume in the Post-Thrombectomy Patients After Large Vessel Occlusion

Stroke ◽

10.1161/str.52.suppl_1.p362 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Riwaj Bhagat ◽

Krishna Madireddy ◽

Shivani Naik ◽

Gopika Kutty ◽

Wei Liu

Keyword(s):

Symptom Onset ◽

Diffusion Weighted Imaging ◽

Infarct Volume ◽

Time Frame ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Computed Tomography Perfusion ◽

Time Frames ◽

Core Volume

Introduction: The Computed Tomography Perfusion (CTP) RAPID software is widely used for the patient selection for mechanical thrombectomy (MT) after anterior circulation large vessel occlusion (LVO). There is a notion that it overestimates the core volume (CV) in an earlier time frame from symptom onset. We compared the accuracy of CTP RAPID estimated CV in different time frames with diffusion weighted imaging (DWI) infarct volume (IV). Method: A retrospective data review of patients who underwent MT for anterior circulation LVO with TICI 2b/3 reperfusion from 2017 to 2019 was done. Patients with baseline CTP and follow up 36-hour MRI was included. Patients with parenchymal hematoma, graded as per ECASS II classification were excluded. CTP time was dichotomized as 0-3 hours (hrs) and >3 hrs from symptom onset. DWI IV was calculated by ABC/2 formula. The volumetric difference (VD), defined as DWI IV minus CTP CV, core volume overestimation (CVO), defined as CTP CV minus DWI IV and CT ASPECTS was calculated. Large CV was defined as >50 ml CV. Standard descriptive statistics and independent sample T-test were used as statistical tools. Result: Total MT cases (n) were 61. Mean age (y.o) was 66 (SD 13.9) (male 57.4%). In < 3 hrs from symptom onset (n 27), mean CTP CV was 38.8 ml (SD 39.8), DWI IV was 39.6 ml (SD 51.4), VD was 0.9 ml (SD 55.2) (p 0.945) and CVO (n 11) was 39.6 ml (SD 35.7) (p 0.008). Mean large CV (n 8) was 78.3 ml (SD 25.4) with median CT ASPECTS of 8 (IQR 6.5-9) and median mRS at discharge 2 (IQR 0.8- 3.3). In >3 hrs from symptom onset (n 34), mean CTP CV was 28.81 ml (SD 47.4), DWI IV was 75.3 ml (SD 69.5), VD was 46.5 ml (SD 61.8) (p 0.002) and CVO (n 5) was 25.2 ml (SD 41.27) (p 0.60). Mean large CV (n 5) was 116.8 ml (SD 75.3) with median CT ASPECTS of 6 (IQR 5-7) and median mRS at discharge 5 (IQR 4- 6). Conclusion: Overestimated core volume on CTP was seen in more than one third cases within 3 hours from symptom onset. Large CV estimated within this time frame had higher CT ASPECTS and good functional outcome at discharge.

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Abstract T P26: Combining Clinical and Imaging Data to Develop a Highly Predictive Model of Outcomes in the MR RESCUE Trial

Stroke ◽

10.1161/str.46.suppl_1.tp26 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Chelsea S Kidwell ◽

Reza Jahan ◽

Jeffrey Gornbein ◽

Jeffry R Alger ◽

Val Nenov ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Infarct Volume ◽

Patient Characteristics ◽

Hemorrhagic Transformation ◽

Imaging Data ◽

Vascular Events ◽

Vessel Occlusion ◽

Intermediate Variables ◽

Core Volume

Background: Identifying patient characteristics that predict outcomes in acute ischemic stroke may assist in triaging those who are candidates for endovascular therapies. We sought to identify predictors of outcome in the overall Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE) cohort and compare results to the previously validated Totaled Health Risks in Vascular Events (THRIVE) score. Methods: MR RESCUE randomized 118 acute ischemic stroke patients with multimodal imaging to embolectomy or standard care within 8 hours of onset. For this analysis, we investigated 17 baseline variables (e.g. age, predicted core volume, time to enrollment) and 8 intermediate variables (e.g. hemorrhagic transformation, day 7 recanalization, final infarct volume) with the potential to impact outcomes (day 90 mRS). The baseline variables were analyzed employing bivariate and multivariate methods (random forest and logistic regression). Two models were developed, one including only significant baseline variables, and the second also incorporating significant intermediate variables. Results: A multivariate model (Table) employing only baseline covariates achieved an overall accuracy (C statistic) of 85% in predicting poor outcome (day 90 mRS 3-6) compared to 80.5% for the THRIVE score. A second model (Table) adding significant intermediate variables achieved 89% accuracy in predicting day 90 mRS. Conclusions: In the MR RESCUE trial, advanced imaging variables, including predicted core volume and site of vessel occlusion, contributed to a highly accurate multivariable model of outcome. In the development phase, this model achieved higher accuracy than the THRIVE score. Future studies are needed to validate this model in an independent cohort.

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Qualitative Posttreatment Diffusion-Weighted Imaging as a Predictor of 90-day Outcome in Stroke Intervention

Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques ◽

10.1017/cjn.2019.330 ◽

2019 ◽

Vol 47 (2) ◽

pp. 160-166

Author(s):

Adam A Dmytriw ◽

Abdullah Alrashed ◽

Alejandro Enriquez-Marulanda ◽

Shadi Daghighi ◽

Ghouth Waggas ◽

...

Keyword(s):

Diffusion Weighted Imaging ◽

Infarct Volume ◽

Multivariable Analysis ◽

Poor Performance ◽

Recombinant Tissue Plasminogen Activator ◽

National Institutes Of Health ◽

Infarct Core ◽

Vessel Occlusion ◽

Subjective Impression ◽

Diffusion Weighted

ABSTRACT:Purpose:The aim was to assess the ability of post-treatment diffusion-weighted imaging (DWI) to predict 90-day functional outcome in patients with endovascular therapy (EVT) for large vessel occlusion in acute ischemic stroke (AIS).Methods:We examined a retrospective cohort from March 2016 to January 2018, of consecutive patients with AIS who received EVT. Planimetric DWI was obtained and infarct volume calculated. Four blinded readers were asked to predict modified Rankin Score (mRS) at 90 days post-thrombectomy.Results:Fifty-one patients received endovascular treatment (mean age 65.1 years, median National Institutes of Health Stroke Scale (NIHSS) 18). Mean infarct volume was 43.7 mL. The baseline NIHSS, 24-hour NIHSS, and the DWI volume were lower for the mRS 0–2 group. Also, the thrombolysis in cerebral infarction (TICI) 2b/3 rate was higher in the mRS 0–2 group. No differences were found in terms of the occlusion level, reperfusion technique, or recombinant tissue plasminogen activator use. There was a significant association noted between average infarct volume and mRS at 90 days. On multivariable analysis, higher infarct volume was significantly associated with 90-day mRS 3–5 when adjusted to TICI scores and occlusion location (OR 1.01; CI 95% 1.001–1.03; p = 0.008). Area under curve analysis showed poor performance of DWI volume reader ability to qualitatively predict 90-day mRS.Conclusion:The subjective impression of DWI as a predictor of clinical outcome is poorly correlated when controlling for premorbid status and other confounders. Qualitative DWI by experienced readers both overestimated the severity of stroke for patients who achieved good recovery and underestimated the mRS for poor outcome patients. Infarct core quantitation was reliable.

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Mo1481 The Impact of Impedance (MII) Testing on Patient Selection for Anti-Reflux Surgery in the Setting of a Normal 24-Hour pH Test

Gastroenterology ◽

10.1016/s0016-5085(12)64173-0 ◽

2012 ◽

Vol 142 (5) ◽

pp. S-1074

Author(s):

Ashwin A. Kurian ◽

Ahmed Sharata ◽

Neil H. Bhayani ◽

Kevin M. Reavis ◽

Christy M. Dunst ◽

...

Keyword(s):

Patient Selection ◽

Selection For ◽

The Impact

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Longer procedural times are independently associated with symptomatic intracranial hemorrhage in patients with large vessel occlusion stroke undergoing thrombectomy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-012157 ◽

2016 ◽

Vol 8 (12) ◽

pp. 1217-1220 ◽

Cited By ~ 16

Author(s):

Tareq Kass-Hout ◽

Omar Kass-Hout ◽

Chung-Huan Johnny Sun ◽

Taha A Kass-Hout ◽

Raul Nogueira ◽

...

Keyword(s):

Intracranial Hemorrhage ◽

Functional Outcomes ◽

Infarct Volume ◽

National Institutes Of Health ◽

Procedure Time ◽

Vessel Occlusion ◽

Procedural Time ◽

Symptomatic Intracranial Hemorrhage

BackgroundTime to reperfusion is an essential factor in determination of outcomes in acute ischemic stroke (AIS).ObjectiveTo establish the effect of the procedural time on the clinical outcomes of patients with AIS.MethodsData from all consecutive patients who underwent mechanical thrombectomy between September 2010 and July 2012 were analysed retrospectively. The variable of interest was procedural time (defined as time from groin puncture to final recanalization time). Outcome measures included the rates of symptomatic intracranial hemorrhage (sICH, defined as any parenchymal hematoma—eg, PH-1/PH-2), final infarct volume, 90-day mortality, and independent functional outcomes (modified Rankin Scale 0–2) at 90 days.ResultsThe cohort included 242 patients with a mean age of 65.5±14.2 and median baseline National Institutes of Health Stroke Scale score 20. 51% of the patients were female. The mean procedure time was significantly shorter in patients with a good outcome (86.7 vs 73.1 min, respectively, p=0.0228). Patients with SICH had significantly higher mean procedure time than patients without SICH (79.67 vs 104.5 min, respectively; p=0.0319), which remained significant when controlling for the previous factors (OR=0.974, 95% CI 0.957 to 0.991). No correlation was found between the volume of infarction and the procedure time (r=0.10996, p=0.0984). No association was seen between procedure time and 90-day mortality (77.8 vs 88.2 min in survivals vs deaths, respectively; p=0.0958).ConclusionsOur data support an association between the risk of SICH and a longer procedure time, but no association between procedural times and the final infarction volume or long-term functional outcomes was found.

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