Selection Paradigms for Large Vessel Occlusion Acute Ischemic Stroke Endovascular Therapy

Background: Optimal patient selection methods for thrombectomy in large vessel occlusion stroke (LVOS) are yet to be established. We sought to evaluate the ability of different selection paradigms to predict favorable outcomes. Methods: Review of a prospectively collected database of endovascular patients with anterior circulation LVOS, adequate CT perfusion (CTP), National Institutes of Health Stroke Scale (NIHSS) ≥10 from September 2010 to March 2016. Patients were retrospectively assessed for thrombectomy eligibility by 4 mismatch criteria: Perfusion-Imaging Mismatch (PIM): between CTP-derived perfusion defect and ischemic core volumes; Clinical-Core Mismatch (CCM): between age-adjusted NIHSS and CTP core; Clinical-ASPECTS Mismatch (CAM-1): between age-adjusted NIHSS and ASPECTS; Clinical-ASPECTS Mismatch (CAM-2): between NIHSS and ASPECTS. Outcome measures were inclusion rates for each paradigm and their ability to predict good outcomes (90-day modified Rankin Scale 0-2). Results: Three hundred eighty-four patients qualified. CAM-2 and CCM had higher inclusion (89.3 and 82.3%) vs. CAM-1 (67.7%) and PIM (63.3%). Proportions of selected patients were statistically different except for PIM and CAM-1 (p = 0.19), with PIM having the highest disagreement. There were no differences in good outcome rates between PIM(+)/PIM(-) (52.2 vs. 48.5%; p = 0.51) and CAM-2(+)/CAM-2(-) (52.4 vs. 38.5%; p = 0.12). CCM(+) and CAM-1(+) had higher rates compared to nonselected counterparts (53.4 vs. 38.7%, p = 0.03; 56.6 vs. 38.6%; p = 0.002). The abilities of PIM, CCM, CAM-1, and CAM-2 to predict outcomes were similar according to the c-statistic, Akaike and Bayesian information criterion. Conclusions: For patients with NIHSS ≥10, PIM appears to disqualify more patients without improving outcomes. CCM may improve selection, combining a high inclusion rate with optimal outcome discrimination across (+) and (-) patients. Future studies are warranted.

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Abstract 39: CT Perfusion Selection May Lead to Better Clinical Outcomes Following Endovascular Therapy in Large Vessel Occlusion Stroke

Stroke ◽

10.1161/str.48.suppl_1.39 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Mehdi Bouslama ◽

Diogo C Haussen ◽

Jonathan A Grossberg ◽

Seena Dehkharghani ◽

Meredith Bowen ◽

...

Keyword(s):

Endovascular Therapy ◽

Functional Outcomes ◽

Ct Perfusion ◽

Univariate Analysis ◽

Information Criterion ◽

Stent Retriever ◽

Large Vessel ◽

Control Analysis ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Background and Purpose: Different imaging paradigms have been used to select patients for endovascular therapy (ET) in large vessel occlusion stroke (LVOS). We sought to determine whether CT perfusion (CTP) selection improves ET outcomes as compared to non-contrast CT (NCCT) alone. Methods: Review of a prospective single-center interventional database of consecutive patients between September 2010 and March 2016. Patients with anterior circulation strokes undergoing stent-retriever thrombectomy were categorized according to imaging selection: (1) CTP and (2) NCCT alone. Two separate analyses were performed: (1) Uni- and Multivariate analyses of the overall cohort and (2) Matched analysis based on age, baseline NIHSS, and glucose levels. Results: A total of 602 patients were included. CTP-selected patients (n=365; 61%) were younger (p=0.02) and had less comorbidities. On univariate analysis, CTP-selection was associated with higher rates of full reperfusion (mTICI-3, p<0.001), good outcomes (90-day mRS 0-2, p=0.005), lower mortality rates (p=0.005), and a favorable shift in the overall distribution of 90-day mRS (p<0.001) as compared with NCCT alone. The rates of any parenchymal hematoma were comparable between groups (p=0.671). Multivariate logistic regression showed that CTP was independently associated with mTICI-3 (OR=1.79 95%CI [1.27-2.53], p=0.001) and good outcomes (aOR=1.72 95%CI [1.10-2.67], p=0.017). In the matched case-control analysis (n=424 patients), CTP-selection was associated with a favorable shift in the distribution of 90-day mRS (p=0.016), lower 90-day mortality (p=0.02), higher rates of mTICI-3 reperfusion (p<0.001), and a trend towards higher rates of 90-day independence (p=0.06). There was an advantage in the ability of CTP to determine functional outcomes in patients presenting later than 6h (Akaike information criterion (AIC) 199.35 vs. 287.49 and Bayesian information criterion (BIC) 196.71 vs 283.27) and with an ASPECTS ≤7 (AIC 216.69 vs 334.96 and BIC 213.6 vs 329.94). Conclusion: CTP-based selection is associated with a favorable shift in functional outcomes in patients undergoing stent-retriever thrombectomy. Future prospective studies are warranted.

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Abstract 60: Impact of Monthly Testing and Tutorials on Accuracy and Confidence of Telestroke Nurse Recognition of Anterior Circulation Large Vessel Occlusion CT Perfusion Patterns

Stroke ◽

10.1161/str.51.suppl_1.60 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Emily K Snider ◽

Brenda Chang ◽

Anna Maria Helms ◽

Laura Williams ◽

Sam Singh ◽

...

Keyword(s):

Good Accuracy ◽

Internal Carotid ◽

Ct Perfusion ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Confidence Levels ◽

Lower Confidence ◽

The Impact

Introduction: A distinguishing feature of our Stroke Network is Telestroke (TS) nurses (RNs) who remotely facilitate TS evaluations. To facilitate expeditious transfer the TS RNs, need to immediately identify CT perfusion (CTP) studies demonstrating patterns consistent with internal carotid artery (ICA), middle cerebral artery (M1), and first branch of the M1 (M2) large vessel occlusion (LVO) acute ischemic strokes (AIS). Methods: We developed a 6-month series of tutorials and tests (12 CTP scans/month) for 16 TS RNs to recognize CTP patterns consistent with ICA, M1 or M2 LVO AIS. We simultaneously conducted a prospective cohort study of these nurses on the impact of these tutorials and tests. Results: TS nurses demonstrated good accuracy in detecting ICA, M1 or M2 LVO presence during the first three months of teaching (83-94% accurate).This improved to excellent during the last three months (99-100%), during which the likelihood of correctly identifying the presence of any one of these LVOs was greater than in the first three months (OR 1.99, 95% CI: 1.83-2.17, p<0.001). The probability of correctly identifying ICA or M1 occlusions was much higher than correctly identifying all other LVOs (OR 68, 95% CI: 45-102, p<0.001). The likelihood of being at a higher confidence level compared to lower confidence levels in identifying any LVOs as being ICA or M1 was higher than in identifying other LVOs (OR 2.14, 95% CI: 1.6-2.8, p<0.001), but over time confidence for determining LVO presence did not differ significantly after controlling for subject variation. Conclusion: A series of structured tutorials significantly increased the odds of TS nurses correctly identifying anterior circulation LVOs, with the benefit of these tutorials and test reviews peaking and plateauing at four months. Participating in TS nurse tutorials was associated with high odds and confidence for correctly identifying LVOs as being ICA or M1.

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Abstract WP82: Evaluation of Infarct Core Determination in Patients With Large Vessel Occlusion

Stroke ◽

10.1161/str.51.suppl_1.wp82 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Victor Lopez-Rivera ◽

James Fan ◽

Songmi Lee ◽

Aditya Kumar ◽

Mehmet Enes Inam ◽

...

Keyword(s):

Ct Perfusion ◽

Infarct Volume ◽

Large Vessel ◽

Late Time ◽

Large Vessel Occlusion ◽

Mri Findings ◽

Infarct Core ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Optimal Method

Introduction: Estimation of infarct core (IC) is a critical component in the evaluation of patients with large vessel occlusion (LVO) for endovascular stroke therapy (EST), but the optimal method to determine IC is uncertain. Methods: From our prospectively maintained institutional registry, we identified acute ischemic stroke (AIS) patients with LVO between 1/2018 and 2/2019. Patients were included if they underwent consecutively and technically adequate non-contrast CT, CT angiography (CTA), and CT Perfusion (CTP). ASPECTS was assessed by an experienced neuroradiologist. CTP IC was determined using RAPID. Final infarct volume (FIV) was determined by manual volume segmentation on DWI sequences from 24h MRI, but this analysis was limited to patients who underwent EST with TICI 2b/3 reperfusion within 120 minutes of presentation CT imaging, to minimize IC growth affecting the results. Correlation between IC measurements was calculated using Spearman p. Results are provided as median [IQR]. Results: Among 772 patients with LVO, 199 patients met inclusion criteria. Median age was 69 [59-79], 47% were female and 57% were white. Median NIHSS was 15 [9-21], the most common occlusion site was M1 MCA (55%). Median CT ASPECTS was 7 [6-9], median CTA ASPECTS was 6 [5-7], and median CTP-RAPID IC volume was 11 [0-47]. Presentation CT ASPECTS correlated with CTP-RAPID IC (Fig. 1A, r=-0.57; p<0.0001), as did CTA ASPECTS (Fig. 1B, r=-0.61; p<0.0001). Presentation CTA ASPECTS correlated with CTP-RAPID IC in patients presenting 0-6 hrs (CTA r=-0.69; p<0.0001) and 6-24 hrs (r=-0.58; p<0.0001). Among 90 patients with EST and TICI 2b/3, presentation CTA ASPECTS correlated better with FIV (r=-0.65; p<0.0001) compared to presentation CTP-RAPID (r=0.61; p<0.0001). Conclusions: In patients with LVO in the anterior circulation, CTA ASPECTS correlated well with CTP-RAPID IC in the early and late time windows, and was more reflective of 24h MRI findings in patients who received EST.

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CT perfusion based ASPECTS improves the diagnostic performance of early ischemic changes in large vessel occlusion

BMC Medical Imaging ◽

10.1186/s12880-021-00593-5 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Tiegong Wang ◽

Luguang Chen ◽

Xianglan Jin ◽

Yuan Yuan ◽

Qianwen Zhang ◽

...

Keyword(s):

Clinical Outcome ◽

Diagnostic Performance ◽

Ct Perfusion ◽

Roc Curves ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Scoring Method ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Poor Outcomes

Abstract Background ASPECTS scoring method varies, but which one is most suitable for predicting the prognosis still unclear. We aimed to evaluate the diagnostic performance of Automated (Auto)-, noncontrast CT (NCCT)- and CT perfusion (CTP) -ASPECTS for early ischemic changes (EICs) in acute ischemic stroke patients with large vessel occlusion (LVO) and to explore which scoring method is most suitable for predicting the clinical outcome. Methods Eighty-one patients with anterior circulation LVO were retrospectively enrolled and grouped as having a good (0–2) or poor (3–6) clinical outcome using a 90-day modified Rankin Scale score. Clinical characteristics and perfusion parameters were compared between the patients with good and poor outcomes. Differences in scores obtained with the three scoring methods were assessed. Diagnosis performance and receiver operating characteristic (ROC) curves were used to evaluate the value of the three ordinal or dichotomized ASPECTS methods for predicting the clinical outcome. Results Sixty-three patients were finally included, with 36 (57.1%) patients having good clinical outcome. Significant differences were observed in the ordinal or dichotomized Auto-, NCCT- and CTP-ASPECTS between the patients with good and poor clinical outcomes (all p < 0.01). The areas under the curves (AUCs) of the ordinal and dichotomized CTP-ASPECTS were higher than that of the other two methods (all p < 0.01), but the AUCs of the Auto-ASPECTS was similar to that of the NCCT-ASPECTS (p > 0.05). Conclusions The CTP-ASPECTS is superior to the Auto- and NCCT-ASPECTS in detecting EICs in LVO. CTP-ASPECTS with a cutoff value of 6 is a good predictor of the clinical outcome at 90-day follow-up.

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Factors associated with prominent vessel sign on susceptibility-weighted imaging in acute ischemic stroke

Scientific Reports ◽

10.1038/s41598-021-84269-8 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Hai-fei Jiang ◽

Yi-qun Zhang ◽

Jiang-xia Pang ◽

Pei-ning Shao ◽

Han-cheng Qiu ◽

...

Keyword(s):

Ischemic Stroke ◽

Large Vessel ◽

Susceptibility Weighted Imaging ◽

Regression Analyses ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Factors Associated ◽

Univariate Analyses

AbstractThe prominent vessel sign (PVS) on susceptibility-weighted imaging (SWI) is not displayed in all cases of acute ischemia. We aimed to investigate the factors associated with the presence of PVS in stroke patients. Consecutive ischemic stroke patients admitted within 24 h from symptom onset underwent emergency multimodal MRI at admission. Associated factors for the presence of PVS were analyzed using univariate analyses and multivariable logistic regression analyses. A total of 218 patients were enrolled. The occurrence rate of PVS was 55.5%. Univariate analyses showed significant differences between PVS-positive group and PVS-negative group in age, history of coronary heart disease, baseline NIHSS scores, total cholesterol, hemoglobin, anterior circulation infarct, large vessel occlusion, and cardioembolism. Multivariable logistic regression analyses revealed that the independent factors associated with PVS were anterior circulation infarct (odds ratio [OR] 13.7; 95% confidence interval [CI] 3.5–53.3), large vessel occlusion (OR 123.3; 95% CI 33.7–451.5), and cardioembolism (OR 5.6; 95% CI 2.1–15.3). Anterior circulation infarct, large vessel occlusion, and cardioembolism are independently associated with the presence of PVS on SWI.

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White Matter Acute Infarct Volume After Thrombectomy for Anterior Circulation Large Vessel Occlusion Stroke is Associated with Long Term Outcomes

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2020.105567 ◽

2021 ◽

Vol 30 (3) ◽

pp. 105567

Author(s):

Robert W. Regenhardt ◽

Mark R. Etherton ◽

Alvin S. Das ◽

Markus D. Schirmer ◽

Joshua A. Hirsch ◽

...

Keyword(s):

White Matter ◽

Infarct Volume ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Long Term Outcomes ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Acute Infarct

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Feasibility and safety of the strategy of first stenting without retrieval using Solitaire FR as a treatment for emergent large-vessel occlusion due to underlying intracranial atherosclerosis

Journal of Neurosurgery ◽

10.3171/2020.8.jns202504 ◽

2021 ◽

pp. 1-9

Author(s):

Jong-Hoon Kim ◽

Young-Jin Jung ◽

Chul-Hoon Chang

Keyword(s):

Functional Outcomes ◽

Medical Center ◽

Large Vessel ◽

Intracranial Atherosclerosis ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Stent Retrieval ◽

First Pass ◽

Solitaire Fr

OBJECTIVEThe optimal treatment for underlying intracranial atherosclerosis (ICAS) in patients with emergent large-vessel occlusion (ELVO) remains unclear. Reocclusion during endovascular treatment (EVT) occurs frequently (57.1%–77.3%) after initial recanalization with stent retriever (SR) thrombectomy in ICAS-related ELVO. This study aimed to compare treatment outcomes of the strategy of first stenting without retrieval (FRESH) using the Solitaire FR versus SR thrombectomy in patients with ICAS-related ELVO.METHODSThe authors retrospectively reviewed consecutive patients with acute ischemic stroke and intracranial ELVO of the anterior circulation who underwent EVT between January 2017 and December 2019 at Yeungnam University Medical Center. Large-vessel occlusion (LVO) of the anterior circulation was classified by etiology as follows: 1) no significant stenosis after recanalization (embolic group) and 2) remnant stenosis > 70% or lesser degree of stenosis with a tendency toward reocclusion and/or flow impairment during EVT (ICAS group). The ICAS group was divided into the SR thrombectomy group (SR thrombectomy) and the FRESH group.RESULTSA total of 105 patients (62 men and 43 women; median age 71 years, IQR 62.5–79 years) were included. The embolic, SR thrombectomy, and FRESH groups comprised 66 (62.9%), 26 (24.7%), and 13 (12.4%) patients, respectively. There were no significant differences between the SR thrombectomy and FRESH groups in symptom onset–to-door time, but puncture-to-recanalization time was significantly shorter in the latter group (39 vs 54 minutes, p = 0.032). There were fewer stent retrieval passes but more first-pass recanalizations in the FRESH group (p < 0.001). Favorable functional outcomes were significantly more frequent in the FRESH group (84.6% vs 42.3%, p = 0.017).CONCLUSIONSThis study’s findings suggest that FRESH, rather than rescue stenting, could be a treatment option for ICAS-related ELVO.

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Abstract 31: Penumbra Consumption Rates Based on T Max Delay and Reperfusion Status: A Post-Hoc Analysis of the Defuse-3 Trial

Stroke ◽

10.1161/str.52.suppl_1.31 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Shadi Yaghi ◽

Eytan Raz ◽

Seena Dehkharghani ◽

Howard Riina ◽

Ryan McTaggart ◽

...

Keyword(s):

Infarct Volume ◽

Secondary Analysis ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Consumption Rates ◽

Definition Of ◽

Post Hoc ◽

New Generation

Introduction: In patients with acute large vessel occlusion, the definition of penumbral tissue based on T max delay perfusion imaging is not well established in relation to late-window endovascular thrombectomy (EVT). In this study, we sought to evaluate penumbra consumption rates for T max delays in patients treated between 6 and 16 hours from last known normal. Methods: This is a secondary analysis of the DEFUSE-3 trial, which included patients with an acute ischemic stroke due to anterior circulation occlusion within 6-16 hours of last known normal. The primary outcome is percentage penumbra consumption defined as (24 hour infarct volume-core infarct volume)/(Tmax volume-baseline core volume). We stratified the cohort into 4 categories (untreated, TICI 0-2a, TICI 2b, and TICI3) and calculated penumbral consumption rates. Results: We included 143 patients, of which 66 were untreated, 16 had TICI 0-2a, 46 had TICI 2b, and 15 had TICI 3. In untreated patients, a median (IQR) of 48% (21% - 85%) of penumbral tissue was consumed based on Tmax6 as opposed to 160.6% (51% - 455.2%) of penumbral tissue based on Tmax10. On the contrary, in patients achieving TICI 3 reperfusion, a median (IQR) of 5.3% (1.1% - 14.6%) of penumbral tissue was consumed based on Tmax6 and 25.7% (3.2% - 72.1%) of penumbral tissue based on Tmax10. Conclusion: Contrary to prior studies, we show that at least 75% of penumbral tissue with Tmax > 10 sec delay can be salvaged with successful reperfusion and new generation devices. In untreated patients, since infarct expansion can occur beyond 24 hours, future studies with delayed brain imaging are needed to determine the optimal T max delay threshold that defines penumbral tissue in patients with proximal anterior circulation large vessel occlusion.

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Abstract 202: Endovascular Therapy for Acute Ischemic Stroke With Distal Large Vessel Occlusion in the Anterior Circulation

Stroke ◽

10.1161/str.47.suppl_1.202 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Amrou Sarraj ◽

Navdeep Sangha ◽

Muhammad Shazam Hussain ◽

Dolora Wisco ◽

Nirav Vora ◽

...

Keyword(s):

Endovascular Therapy ◽

Primary Outcome ◽

Large Vessel ◽

Secondary Outcome ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Good Outcome ◽

Baseline Characteristics ◽

Iv Tpa

Introduction: Five RCTs demonstrated the superiority of endovascular therapy (EVT) over best medical management (MM) for acute ischemic strokes (AIS) with large vessel occlusion (LVO) in the anterior circulation. Patients with M2 occlusions, however, were underrepresented (95 randomized; 51 EVT treated). Evidence from RCTs of the benefit of EVT for M2 occlusions is lacking, as reflected in the recent AHA guidelines. Methods: A retrospective cohort was pooled from 10 academic centers from 1/12 to 4/15 of AIS patients with LVO isolated to M2 presenting within 8 hours from last known normal (LKN). Patients were divided into EVT and MM groups. Primary outcome was 90 day mRS (good outcome 0-2); secondary outcome was sICH. Logistic regression compared the 2 groups. Univariate and multivariate analyses evaluated predictors of good outcome in the EVT group. Results: Figure 1 shows participating centers, 522 patients (288 EVT and 234 MM) were identified. Table (1) shows baseline characteristics. MM treated patients were older and had higher IV tPA treatment rates, otherwise the 2 groups were balanced. 62.7 % EVT patients had mRS 0-2 at 90 days compared to 35.4 % MM (figure 2). EVT patients had 3 times the odds of good outcome as compared to MM patients (OR: 3.1, 95% CI:2.1-4.4, P <0.001) even after adjustment for age, NIHSS, ASPECTS, IV tPA and LKN to door time (OR: 3.2, 95%CI: 2-5.2, P<0.001). sICH rate was 5.6 %, which was not statistically different than the MM group (table 1, P=0.1). Age, NIHSS, good ASPECTS, LKN to reperfusion time and successful reperfusion mTICI ≥ 2b were independent predictors of good outcome in EVT patients. There was a linear relationship between good outcome and time LKN to reperfusion (Figure 3). Conclusion: Despite inherent limitations of its retrospective design, our study suggests that EVT may be effective and safe for distal LVO (M2) relative to best MM. A trial randomizing M2 occlusions to EVT vs. MM is warranted to confirm these findings.

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