Abstract 3130: A 101 cm 3 Diffusion-Weighted Imaging (DWI) Cerebral Infarct Volume is the Maximum Volume Compatible with Good 30- Day Functional Outcome

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Esteban Cheng-Ching ◽  
Junya Aoki ◽  
Yohei Tateishi ◽  
Dolora Wisco ◽  
Gabor Toth ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Functional Outcome ◽  
Diffusion Weighted Imaging ◽  
Infarct Volume ◽  
Cerebral Infarct ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Stroke Treatment

Background: Several predictors of clinical outcome have been identified in acute ischemic stroke patients, including age, National Institutes of Health Stroke Scale scores (NIHSS), and large vessel occlusion. Predicted infarct volumes are thought to generally correlate with clinical outcome, however, to date, mostly small studies have failed to demonstrate a convincing relationship between Diffusion-weighted imaging (DWI) volumes and clinical outcome, and this correlation is controversial. Hypothesis: We hypothesized that final DWI infarction volumes would correlate with 30-day modified Rankin Score (mRS). We also sought to describe the maximum cerebral infarct volume compatible with a favorable 30 day (mRS of 0-2) outcome. Methods: We retrospectively reviewed a prospectively collected database of acute stroke patients with large vessel occlusion who were potential intra-arterial therapy candidate, which recently incorporated systematically collected imaging data at our large academic medical center. Additional inclusion criteria were MRI on admission as per our hyperacute stroke treatment protocol, and available 30-day mRS (n=91). Final DWI volume was obtained from the last MRI the patient had during their stroke treatment admission. Differences between final DWI volume and 30-day mRS were analyzed using the Kruskal-Wallis test. Results: See Table 1 for DWI volumes by individual mRS. There was a strong overall positive relationship between final DWI volume and 30-day mRS [Kruskall Wallis p= .0047]. No patient with an mRS of 0 had a DWI volume >12.1 cm 3 . No patients with an mRS of ≤1 had an DWI volume over 85 cm 3 , and no patient with a mRS of ≤2 had a DWI volume over 101 cm 3 . Conclusions: Cerebral infarct volumes strongly correlate with 30-day functional outcome, but there is great individual variability. The maximum infarct volume compatible with survival and mild or less disability at 30 days was 101 cm 3 . In this study, the maximum cerebral infarct volume compatible with zero clinical symptoms or disability at 30 days was 12.1 cm 3 .

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

Stroke ◽  
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.

scholarly journals Early recanalization in large-vessel occlusion stroke patients transferred for endovascular treatment

2021 ◽  
pp. neurintsurg-2021-017441
Author(s):  
Nerea Arrarte Terreros ◽  
Agnetha A E Bruggeman ◽  
Isabella S J Swijnenburg ◽  
Laura C C van Meenen ◽  
Adrien E Groot ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Functional Outcome ◽  
Clinical Improvement ◽  
Patient Characteristics ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Imaging Characteristics

BackgroundWe performed an exploratory analysis to identify patient and thrombus characteristics associated with early recanalization in large-vessel occlusion (LVO) stroke patients transferred for endovascular treatment (EVT) from a primary (PSC) to a comprehensive stroke center (CSC).MethodsWe included patients with an LVO stroke of the anterior circulation who were transferred to our hospital for EVT and underwent repeated imaging between January 2016 and June 2019. We compared patient characteristics, workflow time metrics, functional outcome (modified Rankin Scale at 90 days), and baseline thrombus imaging characteristics, which included: occlusion location, thrombus length, attenuation, perviousness, distance from terminus of intracranial carotid artery to the thrombus (DT), and clot burden score (CBS), between early-recanalized LVO (ER-LVO), and non-early-recanalized LVO (NER-LVO) patients.ResultsOne hundred and forty-nine patients were included in the analysis. Early recanalization occurred in 32% of patients. ER-LVO patients less often had a medical history of hypertension (31% vs 49%, P=0.04), and more often had clinical improvement between PSC and CSC (ΔNIHSS −5 vs 3, P<0.01), compared with NER-LVO patients. Thrombolysis administration was similar in both groups (88% vs 78%, P=0.18). ER-LVO patients had no ICA occlusions (0% vs 27%, P<0.01), more often an M2 occlusion (35% vs 17%, P=0.01), longer DT (27 mm vs 12 mm, P<0.01), shorter thrombi (17 mm vs 27 mm, P<0.01), and higher CBS (8 vs 6, P<0.01) at baseline imaging. ER-LVO patients had lower mRS scores (1 vs 3, P=0.02).ConclusionsEarly recanalization is associated with clinical improvement between PSC and CSC admission, more distal occlusions and shorter thrombi at baseline imaging, and better functional outcome.

Impact of intravenous thrombolysis on functional outcome in patients with mild ischemic stroke without large vessel occlusion or rapidly improving symptoms

2019 ◽  
Vol 15 (4) ◽  
pp. 429-437 ◽  
Author(s):  
Marcellina Isabelle Haeberlin ◽  
Ulrike Held ◽  
Ralf W Baumgartner ◽  
Dimitrios Georgiadis ◽  
Philipp O Valko
Keyword(s):  
Ischemic Stroke ◽  
Functional Outcome ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Early Improvement ◽  
Treatment Type ◽  
Best Medical Treatment

Background Optimal treatment strategy in patients with mild ischemic stroke remains uncertain. While functional dependency or death has been reported in up to one-third of non-thrombolyzed mild ischemic stroke patients, intravenous thrombolysis is currently not recommended in this patient group. Emerging evidence suggests two risk factors—rapid early improvement and large vessel occlusion—as main associates of unfavorable outcome in mild ischemic stroke patients not undergoing intravenous thrombolysis. Aims To analyze natural course as well as safety and three-month outcome of intravenous thrombolysis in mild ischemic stroke without rapid early improvement or large vessel occlusion. Methods Mild ischemic stroke was defined by a National Institute of Health Stroke Scale score ≤6. We used the modified Rankin Scale (mRS) to compare three-month functional outcome in 370 consecutive mild ischemic stroke patients without early rapid improvement and without large vessel occlusion, who either underwent intravenous thrombolysis (n = 108) or received best medical treatment (n = 262). Results Favorable outcome (mRS ≤ 1) was common in both groups (intravenous thrombolysis: 91%; no intravenous thrombolysis: 90%). Although intravenous thrombolysis use was independently associated with a higher risk of asymptomatic hemorrhagic transformation (OR = 4.62, p = 0.002), intravenous thrombolysis appeared as an independent predictor of mRS = 0 at three months (OR = 3.33, p < 0.0001). Conclusions Mild ischemic stroke patients without rapidly improving symptoms and without large vessel occlusion have a high chance of favorable three-month outcome, irrespective of treatment type. Patients receiving intravenous thrombolysis, however, more often achieved complete remission of symptoms, which particularly in mild ischemic stroke may constitute a meaningful endpoint.

Abstract TP11: CTA Collateral Status and Final Infarct Distribution Following Thrombectomy in Stroke Patients With Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Khalid Al-Dasuqi ◽  
Seyedmehdi Payabvash ◽  
Anthony Abou Karam ◽  
Sumita Strander ◽  
Sreeja Kodali ◽  
...  
Keyword(s):  
White Matter ◽  
Interaction Analysis ◽  
Infarct Volume ◽  
Large Vessel ◽  
Border Zone ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Deep White Matter ◽  
Major Predictor

Aim: The angiographic collateral status is a major predictor of final infarct volume in patients with large vessel occlusion (LVO). In this study, we assessed the effects of collateral status on final infarct lesion distribution after thrombectomy. Methods: Acute ischemic stroke patients with occluded terminal ICA and/or MCA M1 segment who underwent thrombectomy and had a follow up MRI within a week were included. The angiographic collateral status was evaluated on pre-thrombectomy CTA and graded according to Miteff et al. (Brain 2009;132(8):2231-8). The final infarct lesion was segmented on DWI; and using voxel-wise general linear model, we determined the correlation of final infarct volume with post-thrombectomy TICI (thrombolysis in cerebral infarction) score, and collateral status - as a covariate. Results: Among 106 patients with terminal ICA and/or MCA M1 occlusion in analysis, final infarct volume had a significant correlation with TICI reperfusion score (rho=0.384, p<0.001), CTA collaterals (rho=0.221, p=0.023), and TICIxCollaterals interaction term (rho=0.446, p<0.001). Voxel-wise analysis (Figure) showed that better reperfusion after thrombectomy (i.e. higher TICI) was associated with preservation of MCA territory cortex and deep white matter (green). The voxel-wise interaction analysis of TICI and CTA collateral status showed that poor collateral status is associated with infarction of the MCA-PCA border zone (red). Alternatively, good collaterals may preserve the peripheral edges of the MCA territory and MCA-ACA border zone (blue). Conclusion: A successful thrombectomy in LVO stroke patients can preserve the cortical and deep white matter of MCA territory - including eloquent speech and motor regions - while CTA collateral status mainly determines the fate of the MCA-PCA border zone. On the other hand, lentiform nuclei tend to infarct despite successful reperfusion and good CTA collateral status.

Effect of balloon guide catheter on clinical outcomes and reperfusion in Trevo thrombectomy

2019 ◽  
Vol 11 (9) ◽  
pp. 861-865 ◽  
Author(s):  
Thanh N Nguyen ◽  
Alicia C Castonguay ◽  
Raul G Nogueira ◽  
Diogo C Haussen ◽  
Joey D English ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Acute Stroke ◽  
Stent Retriever ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Good Clinical Outcome ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Guide Catheter

IntroductionThe Solitaire stent retriever registry showed improved reperfusion, faster procedure times, and better outcome in acute stroke patients with large vessel occlusion treated with a balloon guide catheter (BGC) and Solitaire stent retriever compared with a conventional guide catheter. The goal of this study was to evaluate whether use of a BGC with the Trevo stent retriever improves outcomes compared with a conventional guide catheter.MethodsThe TRACK registry recruited 23 sites to submit demographic, clinical, and site adjudicated angiographic and outcome data on consecutive patients treated with the Trevo stent retriever. BGC use was at the discretion of the physician.Results536 anterior circulation patients (of whom 279 (52.1%) had BGC placement) were included in this analysis. Baseline characteristics were notable for younger patients in the BGC group (65.4±15.3 vs 68.1±13.6, P=0.03) and lower rate of hypertension (72% vs 79%, P=0.06). Mean time from symptom onset to groin puncture was longer in the BGC group (357 vs 319 min, P=0.06).Thrombolysis in Cerebral Infarction 2b/3 scores were higher in the BGC cohort (84% vs 75.5%, P=0.01). There was no difference in reperfusion time, first pass effect, number of passes, or rescue therapy. Good clinical outcome at 3 months was superior in patients with BGC (57% vs 40%; P=0.0004) with a lower mortality rate (13% vs 23%, P=0.008). Multivariate analysis demonstrated that BGC use was an independent predictor of good clinical outcome (OR 2; 95% CI 1.3 to 3.1, P=0.001).ConclusionsIn acute stroke patients presenting with anterior circulation large vessel occlusion, use of a BGC with the Trevo stent retriever resulted in improved reperfusion, improved clinical outcome, and lower mortality.

Abstract TP154: Infarct Volume and Prolonged Intubation are Critical Determinants of Inpatient Rehabilitation Cost in Anterior Circulation Large Vessel Occlusion Stroke Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Christopher Streib ◽  
Srikant Rangaraju ◽  
Ashutosh Jadhav ◽  
Tudor Jovin
Keyword(s):  
Infarct Volume ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Inpatient Rehabilitation ◽  
Large Vessel ◽  
P Value ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion

Introduction: Anterior circulation large vessel occlusion (ACLVO) stroke is one of the most devastating stroke subtypes. Significant recent advances, including endovascular thrombectomy, have markedly improved ACLVO stroke outcomes. The economic burden of ACLVO stroke treatment is now an important consideration. Our study investigates the critical determinants of acute inpatient rehabilitation (AIR) cost in ACLVO stroke. Methods: We utilized comprehensive patient-level cost-tracking software to calculate AIR costs for ACLVO stroke patients at our institution between July 2012-October 2014. Cost was calculated from the hospital perspective. Patient demographics, clinical course, neurologic exam, and imaging findings were analyzed. Variables with p-value <0.20 in univariate analysis were included in multivariable analysis to determine significant predictors of AIR cost (p<0.05). Results: 65 patients were included in our analysis (median age 61 [IQR 54-73], median AIR admit NIHSS 12 [6-16]). Univariate analysis results are shown (Figure). In our multivariable analysis the only statistically significant predictors of AIR cost were the patient’s final infarct volume (p<0.001) and intubation >48 hours during the hospitalization (p=0.044). AIR costs increased by $66.46 for every 1 cubic centimeter increase in infarct volume. Conclusion: Infarct volume and intubation >48 hours were significant predictors of AIR cost in ACLVO stroke patients at our institution. ACLVO stroke interventions that limit infarct volume may decrease AIR costs, in addition to avoidance of intubation and aggressive pursuit of extubation when feasible.

scholarly journals Rapid Identification of Large Vessel Occlusion Stroke Subtype in the PreHospital Setting

2019 ◽  
Vol 2 (1) ◽  
Author(s):  
Daniel Torolira, B.S. ◽  
Sara Brown, M.D. ◽  
Fen-Lei Chang, M.D.
Keyword(s):  
Medical Center ◽  
Accurate Determination ◽  
Hospital Setting ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Accurate Identification ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Stroke Subtypes

Background and Hypothesis: Stroke treatment is highly time-sensitive, with an estimated 1.9 million neurons dying per minute during an untreated ischemic stroke. The recent advent of mechanical thrombectomy (MT) and its illustrated safety and efficacy in treating large vessel occlusion (LVO) strokes has generated a need to rapidly identify LVO patients who may otherwise be brought to the nearest hospital, which may not have the capability to perform the procedure. Accurate identification of LVO in the pre-hospital setting would allow immediate EMS transport to an MTcapable Comprehensive Stroke Center, thus reducing time-to-treatment and improving patient outcome. While various grading scales, such as the C-STAT, have been developed for this purpose, all have shown to lack sensitivity and specificity for accurate LVO determination. We hypothesize that a new scale combining common LVO presentations as positive values and those of other stroke subtypes, such as small vessel occlusion (SVO) and cardioembolic stroke (CE), as negative values will increase the accuracy of LVO determination. Methods: This is a retrospective chart review analysis of 86 patients evaluated for stroke between January 2017-May 2018 at the Parkview Regional Medical Center with imaging confirmed LVO, SVO or CE diagnoses.   Results: C-STAT stroke scale had a sensitivity of 54.5% and a specificity of 86.7% in differentiating LVO from other stroke subtypes. Compared to C-STAT, our new model showed a significantly higher sensitivity of 81.8% (p=0.0038) and a nonsignificant decreased specificity of 75.0% (p=0.061).  Conclusion: Our findings suggest that our new scale combining common clinical presentations in LVO stroke patients as positive predictor values and those in SVO and CE stroke patients as negative predictor values may allow for a more accurate determination of LVO stroke in the pre-hospital setting without significant delay. A prospective, larger patient cohort in a pre-hospital setting is needed to validate these findings.

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