Abstract 72: Refining The Pre-treatment Noncontrast CT ASPECTS Threshold For IAT Selection: Pooled Analysis Of The Penumbra Pivotal Study And PICS Registry

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Albert J Yoo ◽  
Zeshan A Chaudhry ◽  
R. Gilberto Gonzalez ◽  
Mayank Goyal ◽  
Andrew Demchuk ◽  
...  
Keyword(s):  
Collaborative Study ◽  
Pairwise Comparison ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Critical Determinant ◽  
Good Outcome ◽  
Ischemic Change ◽  
Pivotal Study ◽  
Noncontrast Ct ◽  
Pre Treatment

Background: Previous studies have demonstrated that the Alberta Stroke Program Early CT Score (ASPECTS) on pre-treatment noncontrast CT (NCCT) can be used to identify patients who will benefit from intra-arterial therapy (IAT). Specifically, an ASPECTS threshold of 7 has been identified as clinically important. We sought to test this threshold and further characterize the clinical impact of pre-treatment ASPECTS (pre-ASPECTS) in a large IAT cohort. Materials and methods: We identified anterior circulation acute ischemic stroke patients treated with the Penumbra Stroke System in the Pivotal Study and the Penumbra Imaging Collaborative Study (PICS). Inclusion criteria for this analysis were evaluable pre-treatment NCCT and available 90-day modified Rankin Scale (mRS) score. Expert readers graded ischemic change on NCCT using ASPECTS and blinded to all clinical information except stroke side. Results: Of 221 patients who fulfilled study criteria, the mean age was 66.0±15.1 years, and median NIHSS score was 16 (IQR 12-21). The cohort was 50.9% (112/220) female. There were 111 (50.2%) right-sided strokes. The target vessel occlusion involved the ICA in 21.9% (48/219), MCA in 77.6% (170/219) and ACA in 0.5% (1/219). The median ASPECTS was 7 (IQR 6-9). TIMI 2-3 reperfusion was achieved in 83% (181/218). Good outcome (mRS 0-2) was achieved in 77 (34.8%) patients at 90 days. Adjusting for age, NIHSS and reperfusion, pre-treatment ASPECTS was an independent predictor of good outcome (O.R. 1.47; 95%C.I.:1.23 to 1.76). Pre-ASPECTS >7 predicted good outcome with a relative risk of 1.80 (95%C.I.:1.23 to 2.64). The proportion of good outcomes was exceedingly low among pre-ASPECTS 0-4 (2.8% [1/36]; Figure ). When trichotomizing pre-ASPECTS at 0-4 (n=36), 5-7 (n=76) and 8-10 (n=109), the median 90-day mRS scores were 6 (IQR 4-6), 3.5 (IQR 2-6) and 3 (IQR 1-4), respectively (p<0.0001). In pairwise comparison, the only significant differences were between pre-ASPECTS 0-4 and the other groups. While there was no effect of reperfusion on outcome among pre-ASPECTS 0-4, TIMI 2-3 reperfusion (p=0.04) and earlier timing of reperfusion (none vs. <300 minutes vs. ≥300 minutes; p=0.03) were associated with better outcomes among pre-ASPECTS 5-10. Conclusions: Pre-treatment NCCT ASPECTS is a critical determinant of outcome following IAT. Pre-ASPECTS 0-4 identifies a population of patients who are highly likely to have dismal outcomes and do not benefit from endovascular reperfusion.

Abstract WMP10: Validation of the Pittsburgh Response to Endovascular Therapy (PRE) Score in IMS3

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Srikant Rangaraju ◽  
Diogo Haussen ◽  
Raul Nogueira ◽  
Fadi Nahab ◽  
Michael Frankel ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Predictive Power ◽  
Risk Groups ◽  
Anterior Circulation ◽  
Conventional Angiography ◽  
Vessel Occlusion ◽  
Derivation Cohort ◽  
Good Outcome ◽  
Pre Treatment ◽  
Score Risk

Background: The Pittsburgh Response to Endovascular therapy (PRE) score incorporates patient’s age, initial NIHSS and pre-treatment CT ASPECTS to predict good outcome in anterior circulation large vessel occlusion (LVO) patients. Further validation of this tool is needed before clinical applicability. Objective: To externally validate the PRE score in a randomized trial cohort of anterior circulation LVO patients. Methods: Patients in IMS3 who had LVO involving the intracranial internal carotid artery (ICA), M1 or M2 middle cerebral artery (MCA) confirmed either by CT or conventional angiography and had a documented pre-randomization CT ASPECTS, baseline NIHSS and 3-month mRS were included. The PRE score was calculated as follows: Age (years)+ 2xNIHSS - 10xASPECTS. The predictive power of the PRE score for good outcome (3-month mRS 0-2) was compared to THRIVE, SPAN and HIAT-2 scores. Rate of achieving mRS 0-2 was compared across previously published PRE score risk categories. Results: 407 patients in IMS3 (Endovascular arm: 319 Control arm: 88) had ICA, M1 or M2 occlusions. The cohort had mean age of 66±12 years, median NIHSS 18 [IQR 14-21], median ASPECTS 8 [IQR 6-9] and 38.2% achieved good outcome (mRS 0-2). Age (p<0.001), NIHSS (p<0.001) and ASPECTS (p<0.001) were independent predictors of good outcome. PRE score had good predictive power for mRS 0-2 (AUC=0.73) and Barthel Index≥95 (AUC=0.71) regardless of the treatment arm (AUC=0.72 in both) or reperfusion status. The predictive power for good outcome was similar to HIAT2 (p=0.9) and THRIVE (p=0.10) and slightly superior to SPAN (p=0.06) (Fig 1A). In the endovascular arm, successful reperfusion predicted good outcome (OR 3.1 p<0.001) independently of the PRE score. Rates of good outcome in PRE score risk groups were comparable to the original PRE score derivation cohort (Fig 1B). Conclusions: Our results confirm the validity of the PRE score as a prognostic tool in anterior circulation LVO stroke patients.

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

Stroke ◽  
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.

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.

Abstract WP39: Mechanical Embolectomy for Acute Ischemic Stroke Beyond Six Hours From Symptom Onset Using Advanced MR Imaging

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ryan McTaggart ◽  
Shadi Yaghi ◽  
Daniel C Sacchetti ◽  
Richard Haas ◽  
Shawna Cutting ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Mr Imaging ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Lesion Volume ◽  
Large Artery ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome

Background: There is very limited data on the use of advanced neuroimaging to select patients with acute ischemic stroke and large vessel occlusion for intraarterial therapy beyond 6 hours from onset. Our aim is to report the outcome of patients with acute ischemic stroke and large artery occlusion who presented beyond 6 hours from onset, had favorable MRI imaging profile, and underwent mechanical embolectomy. Methods: This is a single institution retrospective study between December 1st, 2015, and July 30 th , 2016 with acute ischemic stroke and anterior circulation large vessel occlusion (LVO) with ASPECTS of 6 or more and beyond 6 hours from symptoms onset. Favorable imaging profile was defined as 1) DWI lesion volume (as defined as apparent diffusion coefficient < 620 X 10-6 mm2/s) of 70 mL or less AND 2) Penumbra volume (as defined by volume of tissue with Tmax >6 sec) of 15 mL or greater AND 3) A mismatch ratio of 1.8 or more AND 4) Volume of tissue with perfusion lesion with Tmax > 10 sec is less than 100 mL. Good outcome was defined as a 90 day mRS≤2. Results: In the study period, 41 patients met the inclusion criteria; 22 (53.6%) had favorable imaging profile and underwent mechanical embolectomy. The median age was 75 years (59-92), 68.2% were females; the median time from last known normal to groin puncture was 684.5 minutes (range 363-1628) and the median admission NIHSS score was 17.5 (range 4-28). The rate of good outcomes in this series was similar to that in a patient level pooled meta-analysis of the recent endovascular trials (68.2% vs. 46.0%, p=0.07). The rate of good outcome matches that of the EXTEND-IA trial that selected patients using perfusion imaging (68.2% vs. 71.0%, p = 1.00). None of the patients in our cohort had symptomatic intracereberal hemorrhage. Conclusion: Advanced MR imaging may help select patients with acute ischemic stroke and anterior circulation large vessel occlusion for embolectomy beyond the treatment window used in most endovascular trials.

Abstract WP26: Validation of Predictive Scales of Functional Outcome After Endovascular Therapy Using the REVASCAT Data

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Natalia Perez de la Ossa ◽  
Srikant Rangaraju ◽  
Tudor Jovin ◽  
Anoni Dávalos ◽  
Keyword(s):  
Functional Outcome ◽  
Endovascular Therapy ◽  
Predictive Accuracy ◽  
Functional Independence ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
Best Medical Treatment

Introduction: Various scales have been developed to predict long-term clinical outcome after endovascular therapy (EVT) in stroke patients. The objective of this study was to validate and compare five well-validated scales in terms of predictive accuracy for functional independence in a recent endovascular stroke trial (REVASCAT). Hypothesis: We hypothesize that predictive scales (PRE, THRIVE, HIAT2, SPAN-100, FAR) have good-excellent (AUC>0.7) predictive accuracy for good functional outcome and can predict the beneficial effect of EVT demonstrated in randomized clinical trials. Methods: REVASCAT (Randomized Trial of Revascularization with Solitaire-FR Device versus Best Medical Therapy in the Treatment of Acute Stroke Due to Anterior Circulation Large Vessel Occlusion Presenting within Eight Hours of Symptom Onset) enrolled 206 patients who were randomized to receive EVT or best medical treatment. Five scores (PRE-score, THRIVE, HIAT2, SPAN-100 and FAR-score) were retrospectively calculated on patients who received EVT. Receiver-operator characteristics (ROC) for good outcome (mRS 0-2 at 90 days) for each scale were compared. Using the highest predictive scales, the proportion of patients with good outcome by the score categorized in quartiles was analyzed. Results: 103 patients received EVT in the REVASCAT trial (mean age 65.7, median NIHSS 17). Baseline NIHSS, baseline CT-ASPECTS, age and atrial fibrillation, but not previous iv tPA or DM, were associated with good outcome in multivariable analysis. AUC for good outcome was ≥0.70 for FAR (0.74) and PRE (0.70) scores while SPAN-100 (0.67), HIAT2 (0.65) and THRIVE (0.64) had lower AUCs although differences were not statistically significant. The higher the score on the PRE and FAR scores, the lower the proportion of patients with good outcome (PRE-score: 1QT 44.4%, 2QT 24.4%, 3QT 22.2%, 4 QT 8.9%; FAR-score: 1QT 57.8%, 2QT 22.2%, 3QT 6.7%, 4QT 3.3%). Benefit of EVT accordingly to the score on the different scales will be also presented. Conclusions: Of the 5 stroke scales, FAR and PRE had better predictive accuracy for functional independence after EVT. These tools may facilitate decision making for EVT in anterior circulation large vessel occlusion stroke.

Abstract TP43: Is Unintended Hypothermia After Endovascular Therapy Associated With Improved Functional Outcome of Patients With Acute Ischemic Stroke?

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Christian Hartmann ◽  
Simon Winzer ◽  
Timo Siepmann ◽  
Lars-Peder Pallesen ◽  
Alexandra Prakapenia ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Venous Thromboembolism ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Endovascular Therapy ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
Risk Ratios

Introduction: Hypothermia may be neuroprotective in acute ischemic stroke. Stroke patients with anterior circulation large vessel occlusion (acLVO) who receive endovascular therapy (EVT) are frequently hypothermic after the procedure. We sought to analyze whether this unintended hypothermia was associated with improved functional outcome. Methods: We extracted data of consecutive patients (01/2016-04/2019) from our prospective EVT database that includes all patients screened for EVT at our center. We included patients with acLVO who received EVT and analyzed recanalization (mTICI 2b-3) and complications (i.e., pneumonia, bradyarrhythmia, venous thromboembolism) during the hospital course. We assessed functional outcome at 3 months and analyzed risk ratios (RR) for good outcome (mRS scores 0-2) and mortality of patients who were hypothermic (<36°C) compared to patients who were normothermic ( > 36°C) after EVT. We compared the frequency of complications and calculated RRs for good outcome and mortality in the subgroup with recanalization. Results: Among 674 patients with anterior circulation ischemic stroke, 372 patients received EVT for acLVO (178 [47%] male, age 77 years [65-82], NIHSS score 16 [12 - 20]). Of these, 186 patients (50%) were hypothermic (median [IQR] temperature 35.2°C [34.7-35.6]) and 186 patients were normothermic (media temperature 36.4 [36.2-36.8]) after EVT. At 3 months, 54 of 186 (29.0%) hypothermic patients compared with 65 of 186 (35.0%) normothermic patients had a good outcome (RR, 0.83; 95%CI 0.62-1.12) and 52 of 186 (27.9%) hypothermic patients compared with 46 of 186 (24.7%) normothermic patients had died (RR, 1.13; 95%CI 0.8-1.59). This relation was consistent in 307 patients (82.5% of all EVTs) with successful recanalization (good outcome: RR, 0.85; 95%CI 0.63-1.14.; mortality: RR, 1.05; 95%CI 0.7-1.57). More hypothermic patients suffered pneumonia (37.8% vs. 24.7%; p=0.003) or bradyarrhythmia (55.6% vs. 18.3%; p<0.001). Venous thromboembolism was distributed similarly (5.4% vs. 6.5%; p=0.42). Conclusion: Unintended hypothermia following EVT for acLVO was not associated with improved functional outcome or reduced mortality but an increased complication rate in patients with acute ischemic stroke.

Need for rescue treatment and its implication: stent retriever versus contact aspiration thrombectomy

2019 ◽  
Vol 11 (10) ◽  
pp. 979-983 ◽  
Author(s):  
Dong-Hun Kang ◽  
Jin Woo Kim ◽  
Byung Moon Kim ◽  
Ji Hoe Heo ◽  
Hyo Suk Nam ◽  
...  
Keyword(s):  
Stent Retriever ◽  
First Line ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Aspiration Thrombectomy ◽  
Endovascular Thrombectomy ◽  
Negatively Associated ◽  
Good Outcome ◽  
Rescue Treatment ◽  
First Pass

BackgroudThe need for rescue treatment (RT) may differ depending on first-line modality (stent retriever (SR) or contact aspiration (CA)) in endovascular thrombectomy (EVT). We aimed to investigate whether the type of first-line modality in EVT was associated with the need for RT.MethodsWe identified all patients who underwent EVT for anterior circulation large-vessel occlusion from prospectively maintained registries of 17 stroke centers. Patients were dichotomized into SR-first and CA-first. RT involved switching to the other device, balloon angioplasty, permanent stenting, thrombolytics, glycoprotein IIb/IIIa antagonist, or any combination of these. We compared clinical characteristics, procedural details, and final recanalization rate between the two groups and assessed whether first-line modality type was associated with RT requirement and if this affected clinical outcome.ResultsA total of 955 patients underwent EVT using either SR-first (n=526) or CA-first (n=429). No difference occurred in the final recanalization rate between SR-first (82.1%) and CA-first (80.2%). However, recanalization with the first-line modality alone and first-pass recanalization rates were significantly higher in SR-first than in CA-first. CA-first had more device passes and higher RT rate. The RT group had significantly longer puncture-to-recanalization time (93±48 min versus 53±28 min). After adjustment, CA-first remained associated with RT (OR, 1.367; 95% CI, 1.019 to 1.834). RT was negatively associated with good outcome (OR, 0.597; 95% CI, 0.410 to 0.870).ConclusionCA was associated with requiring RT, while recanalization with first-line modality alone and first-pass recanalization rates were higher with SR. RT was negatively associated with good outcome.

scholarly journals Thrombectomy in DAWN- and DEFUSE-3-Ineligible Patients: A Subgroup Analysis From the BEST Prospective Cohort Study

Neurosurgery ◽  
2019 ◽  
Vol 86 (2) ◽  
pp. E156-E163 ◽  
Author(s):  
James E Siegler ◽  
Steven R Messé ◽  
Heidi Sucharew ◽  
Scott E Kasner ◽  
Tapan Mehta ◽  
...  
Keyword(s):  
Prospective Observational Study ◽  
Large Core ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Safety And Efficacy ◽  
Good Outcome ◽  
Symptomatic Intracerebral Hemorrhage ◽  
P 16 ◽  
Multivariable Regression ◽  
Multicenter Prospective Observational Study

Abstract BACKGROUND Because of the overwhelming benefit of thrombectomy for highly selected trial patients with large vessel occlusion (LVO), some trial-ineligible patients are being treated in practice. OBJECTIVE To determine the safety and efficacy of thrombectomy in DAWN/DEFUSE-3-ineligible patients. METHODS Using a multicenter prospective observational study of consecutive patients with anterior circulation LVO who underwent late thrombectomy, we compared symptomatic intracerebral hemorrhage (sICH) and good outcome (90-d mRS 0-2) among DAWN/DEFUSE-3-ineligible patients to trial-eligible patients and to untreated DAWN/DEFUSE-3 controls. RESULTS Ninety-eight patients had perfusion imaging and underwent thrombectomy &gt;6 h; 46 (47%) were trial ineligible (41% M2 occlusions, 39% mild deficits, 28% ASPECTS &lt;6). In multivariable regression, the odds of a good outcome (aOR 0.76, 95% CI 0.49-1.19) and sICH (aOR 3.33, 95% CI 0.42-26.12) were not different among trial-ineligible vs eligible patients. Patients with mild deficits were more likely to achieve a good outcome (aOR 3.62, 95% CI 1.48-8.86) and less sICH (0% vs 10%, P = .16), whereas patients with ASPECTS &lt;6 had poorer outcomes (aOR 0.14, 95% CI 0.05-0.44) and more sICH (aOR 24, 95% CI 5.7-103). Compared to untreated DAWN/DEFUSE-3 controls, trial-ineligible patients had more sICH (13%BEST vs 3%DAWN [P = .02] vs 4%DEFUSE [P = .05]), but were more likely to achieve a good outcome at 90 d (36%BEST vs 13%DAWN [P &lt; .01] vs 17%DEFUSE [P = .01]). CONCLUSION Thrombectomy is used in practice for some patients ineligible for the DAWN/DEFUSE-3 trials with potentially favorable outcomes. Additional trials are needed to confirm the safety and efficacy of thrombectomy in broader populations, such as large core infarction and M2 occlusions.

Pittsburgh response to endovascular therapy score as a pre-treatment prognostic tool: External validation in Trevo2

2016 ◽  
Vol 12 (5) ◽  
pp. 494-501 ◽  
Author(s):  
Syed Ali Raza ◽  
Bin Xiang ◽  
Tudor G Jovin ◽  
David S Liebeskind ◽  
Ryan Shields ◽  
...  
Keyword(s):  
Patient Selection ◽  
Endovascular Therapy ◽  
Predictive Power ◽  
Large Vessel ◽  
Stroke Severity ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
Pre Treatment

Background Optimal patient selection is needed to maximize the therapeutic benefit of endovascular therapy for large vessel occlusion stroke. Aims To validate the Pittsburgh response to endovascular therapy (PRE) score in a randomized controlled trial (Trevo2) comparing stent retriever (Trevo) to the Merci device. Methods Trevo2 participants with internal carotid, M1 and M2 middle cerebral artery occlusions with prospectively collected baseline stroke severity (NIHSS), degree of hypodensity (CT ASPECTS), and three-month modified Rankin Scale (mRS) were included. Multivariable regression was used to confirm association between PRE score variables (age, NIHSS, and ASPECTS), medical comorbidities, randomization arm, and reperfusion status (mTICI2B/3) with good outcome (three-month modified Rankin Scale 0–2). Predictive power (area under the receiver operating characteristic curve) for good outcome of pre-treatment prognostic scores (PRE, THRIVE, HIAT2) was compared. Rates of good outcome were compared between successfully reperfused (mTICI2B/3) and non-reperfused (mTICI0-2A) patients across previously identified PRE score risk groups. Results Age, NIHSS, ASPECTS, reperfusion status, and randomization arm were independent predictors of good outcome. PRE score had moderate predictive power (AUC = 0.75) for good outcome and was comparable to other pre-treatment scores. Reperfusion resulted in maximal treatment benefit in patients with PRE score 0–24 (60% vs. 12.5%, p = 0.002) but not in those with PRE ≥50 (11.8% vs. 0.0%, p = 0.49). Conclusion The PRE score is a validated predictor of functional outcome and a tool for patient selection for endovascular therapy in anterior large vessel occlusion stroke. Our finding of limited benefit of reperfusion in patients with PRE score ≥50 needs to be prospectively validated.

Abstract 132: Final Infarct Volume is a Critical Determinant of Hospitalization Cost in Anterior Circulation Large Vessel Occlusion Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Christopher Streib ◽  
Srikant Rangaraju ◽  
Daniel G Winger ◽  
David T Campbell ◽  
Stephanie Paolini ◽  
...  
Keyword(s):  
Infarct Volume ◽  
Cost Effective ◽  
Large Vessel ◽  
Sensitivity Analyses ◽  
Large Vessel Occlusion ◽  
Primary Analysis ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Critical Determinant ◽  
Hospitalization Cost

Background: Anterior circulation large vessel occlusion (ACLVO) stroke, one of the most devastating stroke subtypes, is associated with substantial economic burden. Identifying predictors of increased ACLVO stroke hospitalization cost is essential to developing cost-effective treatment strategies. Methods: We utilized comprehensive patient-level cost-tracking software to calculate hospitalization costs for ACLVO stroke patients at our institution between July 2012-October 2014. Patient demographics and neuroimaging findings were analyzed. Predictors of hospitalization cost were determined using multivariable linear regression. In addition to our primary analysis (all eligible ACLVO patients), we conducted subgroup analyses by treatment (endovascular, IV tPA-only, and no reperfusion therapy) and sensitivity analyses. Results: 341 patients (median age 69 [IQR 57-80], median NIHSS 16 [IQR 13-21], median hospitalization cost $16,446 [IQR $9823-$27,165]) were included in our primary analysis; final infarct volume (FIV), parenchymal hematoma, age, obstructive sleep apnea, and baseline NIHSS were significant predictors of hospitalization cost (Figure). FIV alone accounted for 20.51% of the total variance in hospitalization cost. Notably, FIV was consistently the most robust predictor of increased cost across primary, subgroup, and sensitivity analyses. Over the observed range of FIVs in our cohort, each additional 1cc of infarcted brain tissue increased hospitalization cost by $122.35. Conclusion: FIV is a critical determinant of increased hospitalization cost in ACLVO stroke. Therapies resulting in reduced FIV may not only improve clinical outcomes, but prove cost-effective.

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