Abstract WMP17: Early DWI Reversal Following Endovascular Reperfusion Is Typically Transient

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Manabu Inoue ◽  
Hayley M Wheeler ◽  
Michael Mlynash ◽  
Aaryani Tipirneni ◽  
Matus Straka ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Endovascular Therapy ◽  
Independent Predictor ◽  
Infarct Volume ◽  
Prognostic Significance ◽  
Reperfusion Therapy ◽  
Ischemic Lesion ◽  
Stroke Treatment ◽  
Median Volume

Background and Purpose: There are conflicting reports regarding the incidence and prognostic significance of DWI reversal following reperfusion therapy. The aim of this study was to assess the frequency and extent of early DWI reversal following endovascular therapy and to determine if early reversal is sustained or transient. Methods: This is a substudy of the DEFUSE 2. MRI with DWI and PWI was performed before (DWI 1) and within 12 hours after (DWI 2) endovascular stroke treatment and again at 5 days. Acute DWI lesions were outlined and quantified using mipav software (http://mipav.cit.nih.gov/). Ischemic lesion volumes were outlined on the Day 5 FLAIR then corrected for edema using a validated technique to determine the final infarct volume. Early DWI reversal was defined as (DWI 1 - DWI 2) >3 ml and permanent DWI reversal was defined (DWI 1 - final infarct volume) > 1 ml. Reperfusion was defined as a >50% reduction in PWI volume (Tmax >6 sec) on the MRI performed after endovascular therapy. The prognostic significance of early reversal was assessed in a regression model. Results: 104 patients had a technically adequate DWI and PWI prior to endovascular therapy (performed 4.4 [3.0-6.0] hours after symptom onset). Of these, 77 had an acute DWI lesion >3 ml and a follow-up MRI (156 min [72-342] after completion of endovascular therapy) and a 5 day MRI. Seventeen percent (13/77) of the patients had early DWI reversal representing a median (IQR) of 42.4% (25.0-57.6) of the initial DWI lesion (median volume 10.9 ml [IQR 7.3-18.2]). The incidence of early DWI reversal was 21% (11/52) following reperfusion vs. 8% (2/25) in patients who did not reperfuse (p=0.20). Of the 13 patients with early DWI reversal, permanent DWI reversal occurred in only 2 (volume of permanent DWI reversal 6.9 ml and 4.7 ml). Early DWI reversal was not an independent predictor of clinical outcome. Conclusion: Early DWI reversal occurs in about 15-20% of patients following endovascular therapy and can involve a substantial percentage of the initial DWI volume. However, early DWI reversal is usually transient and does not appear to signify tissue salvage.

Abstract 52: Results of DEFUSE 2: Imaging Endpoints

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Gregory W Albers ◽  
Matus Straka ◽  
Stephanie Kemp ◽  
Michael Mlynash ◽  
Tudor G Jovin ◽  
...  
Keyword(s):  
Clinical Response ◽  
Endovascular Therapy ◽  
Infarct Volume ◽  
Reperfusion Therapy ◽  
Early Reperfusion ◽  
Lesion Growth ◽  
Favorable Clinical Response ◽  
Multi Center Study ◽  
Automated Software

Background: The aim of DEFUSE 2 is to determine if predefined MRI profiles predict clinical and imaging outcomes following endovascular reperfusion therapy. Methods: This prospective, NIH funded, multi-center study enrolled consecutive acute stroke patients in whom an MRI scan could be obtained immediately prior to intra-arterial therapy. A follow-up MRI was performed within 12 hrs of completion of the procedure and again at 5 days. PWI and DWI lesion volumes were determined using a fully automated software program (RAPID). Lesion growth (infarct volume on 5 day FLAIR - baseline DWI volume) was compared for patients with and without the Target mismatch profile based on whether early reperfusion occurred. The Target mismatch profile was defined as PWI(Tmax>6s) / DWI >1.8, DWI <70 mL and PWI(Tmax>10s) <100 mL. Early reperfusion was defined as a >50% reduction in PWI volume following the procedure. The incidence and extent of DWI reversal was assessed and the fate of PWI lesions that were not reperfused was determined. Favorable clinical response was defined as an improvement in NIHSS ≥8 or 0-1 at 30 days. Results: This abstract represents a preliminary analysis of 71 of 101 patients who were treated with endovascular therapy (final results to be presented). Among the 54 patients with Target mismatch, early reperfusion was achieved in 70% and was associated with less infarct growth (relative median growth 210% vs. 450%, p=0.01) and a higher rate of favorable clinical response (OR=5.4; 95%CI 1.5-19.2). In patients without the Target mismatch profile (N= 13) early reperfusion was not associated with a reduction in infarct growth (relative median growth was 220% in both reperfusers and non-reperfusers; p=0.94) or an increased rate of favorable clinical response (OR=0.1; 95%CI 0.004-2.2). 96% of all voxels that were DWI positive at baseline were incorporated into the final infarct (assessed on the co-registered 5 day FLAIR); only 3 of 71 patients had FLAIR volumes that were smaller than the baseline DWI lesion (mean difference 3 mL). 80% of the voxels that had a PWI lesion (Tmax>6s) on the post-procedure scan were incorporated into the final infarct. The correlation between the union of the baseline DWI + early follow-up PWI lesion and the 5 day FLAIR volume was high (r=0.84; p< 0.0001). In 82% of the patients, the day 5 FLAIR volume was as at least as large as the union of the baseline DWI + early follow-up PWI lesion. Conclusion: Patients with the Target mismatch profile who achieve early reperfusion following intra-arterial therapy have less infarct growth and more favorable clinical outcomes. In contrast, no benefit of reperfusion was evident for non-Target mismatch patients. Baseline DWI lesions are virtually always fully incorporated into the final infarct volume, regardless of reperfusion. Tissue that remains hypoperfused (Tmax >6s) following endovascular therapy reliably progresses to infarction.

Abstract P338: Incidence, Predictors and Impact of Infarct in New Territory in Escape Na1 Trial

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Nishita Singh ◽  
Martha Marko ◽  
Petra Cimflova ◽  
Johanna Ospel ◽  
Nima Kashani ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Endovascular Therapy ◽  
Randomized Study ◽  
Maximum Diameter ◽  
Vascular Territory ◽  
Poor Clinical Outcome ◽  
Guide Catheter ◽  
Ct And Mri

Introduction: Infarct in new territory (INT) is a known complication of endovascular therapy. We assessed the prevalence, predictors and clinical relevance of INT Methods: We included patients from the ESCAPE-NA1: a multicenter, international randomized study that assessed the efficacy of intravenous nerinetide in patients with acute ischemic stroke who underwent EVT within 12 hours from onset. All imaging was re-evaluated, and INT was defined by presence of infarct in new vascular territory, outside the baseline target occlusion(s) on follow up CT and MRI. INT’s were classified by maximum diameter (<2mm, 2-20mm and >20mm) and location. Results: Of 1099 analyzed patients in ESCAPE NA1, 107 had INT (9.7%, mean age 67 years, 51.4% females). There were no differences at baseline in those with vs without INT. Most INTs (75.7%) were angiographically occult and 41(38.3%) were > 20mm. The most common INT territory was the ACA alone or in combination with MCA/PCA (30.3%). The presence of emboli in new territory angiographically was significantly associated with INT (OR 16.39, 95%CI 8.14-33.09). Alteplase use, balloon guide catheter use, nerinetide and initial occlusion site did not predict INT. INT patients had higher final median infarct volumes compared to non-INT (44.5cc vs 23.3cc, P<0.001). Large INT (diameter of >20mm) were associated with poor clinical outcome compared to INT (<2mm) OR (mRS 0-2) 0.17, 95%CI 0.05-0.55). Conclusion: Infarcts in new territory are common and are associated with poor outcome.

Abstract 188: Correlation of Angiographic Capillary Index Score (CIS) with Diffusion and Perfusion MR Imaging in the DEFUSE 2 Trial

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Michael P Marks ◽  
Firas Al-Ali ◽  
Maarten G Lansberg ◽  
Michael Mlynash ◽  
Stephanie M Kemp ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Lesion Volume ◽  
Collateral Flow ◽  
Point Scale ◽  
Median Volume ◽  
Perfusion Mr ◽  
Lesion Growth ◽  
Perfusion Mr Imaging ◽  
The Relationship

Objective: The CIS has been shown to be a predictor of good clinical outcome following endovascular therapy for acute ischemic stroke. We undertook this study to determine the relationship between CIS and baseline diffusion-perfusion imaging as well as angiographic collaterals in DEFUSE 2 study patients. Methods: Patients undergoing endovascular therapy within 12 hours of stroke onset were prospectively enrolled. Only patients with an ICA/M1 occlusion and adequate demonstration of the anterior and posterior circulations at baseline angiography were included in this analysis. Blinded reading of the CIS was made using a 4 point scale from 0 (no capillary blush in ischemic territory) to 3 (blush throughout). Analysis was dichotomized to poor CIS (0-1) versus good (2-3). CIS was correlated with baseline DWI volume, PWI volume (Tmax > 6, Tmax>10), an angiographic collateral score (using a previously described 5 point scale) and subsequent infarct growth. Results: Forty-eight patients had ICA/M1 occlusions and adequate angiographic images to evaluate CIS. Baseline DWI lesion volume correlated with CIS (p=0.001). Median DWI volume for patients with poor CIS (0-1) was 28 (IQR, 11-54) versus 13 (3-27) for those with good CIS (2-3), p=0.011. Baseline T max > 6 volume correlated with CIS (p=0.004). Median volume of tissue at risk (T max > 6 sec) in those with poor CIS was 108 ml (IQR, 74-138) versus 69(43-108) with good CIS, p=0.009. Severe T max delay (> 10 sec) also correlated with CIS (p=0.001). CIS was also found to correlate with angiographic collaterals (p=0.006). On follow-up MRI CIS correlated with subsequent lesion growth (p=0.043). Conclusions: CIS provides a rapid angiographic assessment of capillary blush from collateral flow into the ischemic territory and correlates with angiographic collateral scores. In DEFUSE 2 the CIS score was strongly associated with baseline DWI and PWI lesion volumes and subsequent lesion growth.

P5472Social economic deprivation and adverse clinical outcomes after acute coronary syndrome

2019 ◽  
Vol 40 (Supplement_1) ◽  
Author(s):  
Y C Lau ◽  
J Latter ◽  
A Jong ◽  
R Weir
Keyword(s):  
Clinical Outcome ◽  
Secondary Prevention ◽  
Clinical Outcomes ◽  
Statistical Difference ◽  
Independent Predictor ◽  
Composite Endpoint ◽  
Socioeconomic Deprivation ◽  
Angiotensin Ii Receptor Blocker ◽  
The Impact

Abstract Background NHS was created in 1948 to redress the healthcare inequality through provision of universal healthcare service in the UK. However even of late, significant health inequality persists. Socioeconomic deprivation is known to result in increased overall morbidity and mortality. Aim To assess the impact of socioeconomic deprivation (as categorised by Scottish Index of Multiple Deprivation, SIMD) on the medical management and clinical outcomes of patients with ACS (NSTEMI/STEMI) who were treated with PCI Methods A retrospective study of NSTEMI/NSTEMI patients after inpatient treatment with coronary angiogram and PCI. The parameters include basic demographics, risk factors, LV EF on echocardiogram, lipid profile and discharge medication. Individual's socioeconomic deprivation index, as described SIMD was also recorded (1 – most deprived and 10 – least deprived), and accordingly placed into quintile (SIMD 1–2, 3–4, 5–6,7 –8, 9–10). Follow-up for 24 months. Clinical outcome assessed was composite endpoint event of MACE. Results 357 from the lowest quintile (SIMD 1–2), 319 from SIMD 3–4, 191 from SIMD 5–6, 120 from SIMD 7–8, and 99 from the highest quintile (SIMD 9–10) were included. No statistical difference exists between age or gender. No difference in past medical history (inclusive of hypertension, diabetes, dyslipidemia, family history. No difference in incidence of nicotine use. Prescription of aspirin, P2Y12 inhibitors (clopidogrel, ticagrelor or prasugrel) as well as secondary prevention medications (such as ace inhibitor/angiotensin II receptor blocker, beta blocker, statin and GTN) were good and not statistically different between all groups. No statistical difference exists between all groups relating to pre-discharge LV ejection fraction on echocardiogram or random cholesterol level check on admission. 24 months follow-up demonstrated composite endpoint of MACE was statistically higher among patients of lowest socioeconomic quintile (Kaplan Meier plot, p<0.001). Step-wise multiple regression analysis also confirmed multiple socioeconomic deprivation as an independent predictor for more adverse clinical outcomes (p<0.001, R2=14.5%). Patients from the least deprived quintile possess survival advantage almost 14-folds as compared to those of most deprived group (Odd-ratio 13.8 (95% CI: 39.4–48.5)). Summary After an ACS event, despite initial coronary intervention and subsequent optimal prescription of prognostically beneficial secondary prevention medications, patients from the lower socioeconomic group (as described by SIMD) are still more likely to experience readmission for cardiovascular death, non-fatal myocardial infarction and non-fatal stroke. Socioeconomic deprivation has been shown to be an independent predictor of adverse clinical outcome for those who survived initial ACS. Acknowledgement/Funding None

Early ischemic lesion on computed tomography: predictor of poor outcome among survivors of aneurysmal subarachnoid hemorrhage

2007 ◽  
Vol 107 (6) ◽  
pp. 1074-1079 ◽  
Author(s):  
Jari Siironen ◽  
Matti Porras ◽  
Joona Varis ◽  
Kristiina Poussa ◽  
Juha Hernesniemi ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Subarachnoid Hemorrhage ◽  
Independent Predictor ◽  
Aneurysmal Subarachnoid Hemorrhage ◽  
Ct Scans ◽  
Ischemic Lesion ◽  
Poor Outcome ◽  
Serial Ct ◽  
Early Lesion

Object Identifying ischemic lesions after subarachnoid hemorrhage (SAH) is important because the appearance of these lesions on follow-up imaging correlates with a poor outcome. The effect of ischemic lesions seen on computed tomography (CT) scans during the first days of treatment remains unknown, however. Methods In 156 patients with SAH, clinical course and outcome, as well as the appearance of ischemic lesions on serial CT scans, were prospectively monitored for 3 months. At 3 months after SAH, magnetic resonance imaging was performed to detect permanent lesions that had not been visible on CT. Results Of the 53 patients with no lesions on any of the follow-up CT scans, four (8%) had a poor outcome. Of the 52 patients with a new hypodense lesion on the first postoperative day CT, 23 (44%) had a poor outcome. Among the remaining 51 patients with a lesion appearing later than the first postoperative morning, 10 (20%) had a poor outcome (p < 0.001). After adjusting for patient age; clinical condition on admission; amounts of subarachnoid, intracerebral, and intraventricular blood; and plasma glucose and D-dimer levels, a hypodense lesion on CT on the first postoperative morning was an independent predictor of poor outcome after SAH (odds ratio 7.27, 95% confidence interval 1.54–34.37, p < 0.05). Conclusions A new hypodense lesion on early postoperative CT seems to be an independent risk factor for poor outcome after SAH, and this early lesion development may be more detrimental to clinical outcome than a later lesion occurrence.

scholarly journals Endothelial dysfunction a significant marker of adverse clinical outcome in patients with atrial fibrillation after cardioembolic stroke

2019 ◽  
Vol 91 (1) ◽  
pp. 53-59
Author(s):  
I A Zolotovskaya ◽  
I L Davydkin
Keyword(s):  
Atrial Fibrillation ◽  
Endothelial Dysfunction ◽  
Clinical Outcome ◽  
Prognostic Significance ◽  
Cardioembolic Stroke ◽  
Adverse Clinical Outcome ◽  
Constant Form ◽  
At Iii ◽  
The Dead

Aim. To study the prognostic significance of endothelial dysfunction (ED) markers in the development of adverse clinical outcome (death) in patients with atrial fibrillation (AF) within a year after cardioembolic stroke. Materials and methods. 260 patients with newly diagnosed (nAF), paroxysmal, persistent and permanent forms of AF who underwent stroke were included. Duration of observation-12 months. V1 - the beginning of the study: V2 - 180 (±5) days and V3 - 360 (±5) evaluated the level of von Willebrand factor (fW), antithrombin III (AT III) and plasminogen. Results and discussion. During the year of follow-up, patients with AF who underwent and had a high mortality rate. During the whole period 38 (14.6%) patients died, 15 (23.0%) - in the group with nAF, 6 (9.2%) - in the group with paroxysmal AF, 7 (10.8%) - in the group with persistent AF and 10 (15.4%) - in the group with permanent AF. After a year of follow-up, the level of fW in patients with nAF was higher than in patients of all groups, and statistically significant in patients with paroxysmal and persistent forms of AF. At III was important in the group of patients with nAF and with a constant form of AF, in the same groups there was no statistically significant increase in a year of follow-up. It was found that in survivors with nAF at III (73.54±8.67%) higher (p=0.002) compared with the dead (65.77±6.01%). In the group of patients with paroxysmal AF in survivors of III (77.75±10.15%) higher (p=0.031) compared with the dead (69.25±5.80%). In patients with persistent AF, the survivors of III (76.57±9.09%) were higher (p=0.002) compared to the dead (65.60±2.21%). Taking into account the results of the analysis of the dynamics of ed markers, it can be assumed that AT III is the most accurate prognostic marker for the studied cohort of patients. Conclusion. Detection and correction of ED in AF in patients within a year after stroke can optimize the tactics of management of patients and improve the prognosis of the diseas.

scholarly journals Prognostic significance of TERT promoter and BRAF mutations in TIR-4 and TIR-5 thyroid cytology

2019 ◽  
Vol 181 (1) ◽  
pp. 1-11 ◽  
Author(s):  
Simona Censi ◽  
Susi Barollo ◽  
Elisabetta Grespan ◽  
Sara Watutantrige-Fernando ◽  
Jacopo Manso ◽  
...  
Keyword(s):  
Independent Predictor ◽  
Prognostic Significance ◽  
Gene Mutations ◽  
Distant Metastases ◽  
Disease Outcome ◽  
Promoter Mutation ◽  
Braf Mutations ◽  
Excellent Outcome ◽  
Tumor Stages

ObjectiveFollicular-derived thyroid cancers generally have a good prognosis, but in a minority of cases, they have an aggressive behavior and develop distant metastases, with an increase in the associated mortality. None of the prognostic markers currently available prior to surgery can identify such cases.MethodsTERTpromoter andBRAFgene mutations were examined in a series of 436 consecutive TIR-4 and TIR-5 nodes referred for surgery. Follow-up (median: 59 months, range: 7–293 months) was available for 384/423 patients with malignant nodes.ResultsTERTpromoter andBRAFmutations were detected in 20/436 (4.6%) and 257/434 thyroid nodules (59.2%), respectively. At the end of the follow-up, 318/384 patients (82.8%) had an excellent outcome, 48/384 (12.5%) had indeterminate response or biochemical persistence, 18/384 (4.7%) had a structural persistence or died from thyroid cancer.TERTpromoter mutations correlated with older age (P < 0.0001), larger tumor size (P = 0.0002), oxyntic and aggressive PTC variants (P = 0.01), higher tumor stages (P < 0.0001), distant metastases (<0.0001) and disease outcome (P < 0.0001). At multivariate analysis,TERTpromoter mutation was not an independent predictor of disease outcome.TERTpromoter mutation- (OR: 40.58; 95% CI: 3.06–539.04), and N1b lymph node metastases (OR: 40.16, 95% CI: 3.48–463.04) were independent predictors of distant metastases.BRAFmutation did not predict the outcome, and it correlated with a lower incidence of distant metastases (P = 0.0201).ConclusionsTERTpromoter mutation proved an independent predictor of distant metastases, giving clinicians the chance to identify many of the patients who warranted more aggressive initial treatment and closer follow-up.

scholarly journals From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke

2021 ◽  
Vol 12 ◽  
Author(s):  
Aravind Ganesh ◽  
Johanna Maria Ospel ◽  
Martha Marko ◽  
Wim H. van Zwam ◽  
Yvo B. W. E. M. Roos ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Healthy Lifestyle ◽  
Standard Of Care ◽  
Stroke Treatment ◽  
Post Stroke ◽  
Treatment Benefits ◽  
Family Social Support ◽  
Modifiable Factors

Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond.Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT.Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability.Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.

scholarly journals Mediation of the Relationship Between Endovascular Therapy and Functional Outcome by Follow-up Infarct Volume in Patients With Acute Ischemic Stroke

2019 ◽  
Vol 76 (2) ◽  
pp. 194 ◽  
Author(s):  
Anna M. M. Boers ◽  
Ivo G. H. Jansen ◽  
Scott Brown ◽  
Hester F. Lingsma ◽  
Ludo F. M. Beenen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Endovascular Therapy ◽  
Infarct Volume ◽  
The Relationship

Abstract 100: Right Insular Infarction is an Independent Predictor of Mortality in Ischemic Stroke

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Laura Hanne ◽  
Peter Brunecker ◽  
Matthias Endres ◽  
Jochen B Fiebach ◽  
Martin Ebinger
Keyword(s):  
Ischemic Stroke ◽  
Multivariate Regression ◽  
Independent Predictor ◽  
Lesion Volume ◽  
Regression Analyses ◽  
Imaging Studies ◽  
Ischemic Lesion ◽  
Patients At Risk ◽  
The Right

Introduction: The association between insular infarction and mortality has often been described. However, whether this is simply due to higher lesion volumes is still controversial. Hypothesis: We hypothesized that there is an association between insular infarction and mortality independent of lesion volume. Methods: We included consecutive stroke patients between 01.09.2008 and 11.11.2012 from the 1000Plus data base with an acute ischemic lesion on diffusion-weighted imaging on day one and a completed 90 days follow-up. Insular location of the infarction was determined using the Stroke Lesion Atlas (SLA). The SLA is an in-house developed spatial database for analyses of imaging studies (Figure). In multivariate regression analyses of mortality and insular infarcts we adjusted for age, lesion volume, atrial fibrillation, NIHSS, capsular infarcts, and left hemispheric infarcts. Results: We included 718 patients. Out of 165 patients with insular infarcts 20 patients died; among the 553 patients with lesions outside the Insula 16 patients died (mortality 12% vs. 3%; p<.001). In analyses adjusting for all mentioned confounders insular infarction was not an independent predictor of mortality. After exclusion of NIHSS insular infarcts were independently associated with mortality (OR=3.003, CI 1.41 - 6.38, p=.004). Right insular infarction was an independent mortality predictor adjusted for all confounders including the NIHSS (OR=2.793, CI 1.27 - 6.15, p=.011). Conclusion: Right insular involvement is an independent predictor of mortality in ischemic stroke and may be used to improve identification of patients at risk. Figure. Lesion overlap of patients who survived (A) or died (B). Red indicates voxels involved in at least 15% of patients. Deceased patients show a maximum lesion overlap in the right Insula.

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