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.

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 WMP9: Impact of Collateral Blood Flow on Clinical Presentation, Diffusion and Perfusion Imaging, Infarct Growth and Clinical Outcome in the DEFUSE 2 Trial

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Michael P Marks ◽  
Maarten G Lansberg ◽  
Michael Mlynash ◽  
John-Marc Olivot ◽  
Matus Straka ◽  
...  
Keyword(s):  
Perfusion Imaging ◽  
Clinical Presentation ◽  
Stroke Severity ◽  
Collateral Flow ◽  
Collateral Blood Flow ◽  
Point Scale ◽  
Median Volume ◽  
And Diffusion ◽  
Blinded Reader ◽  
Good Flow

Objective: To determine the relationships between angiographic collaterals and diffusion/perfusion imaging, subsequent infarct growth and clinical outcomes in DEFUSE 2 study patients. Methods: Patients undergoing endovascular therapy within 12 hours of stroke onset were prospectively enrolled. Only patients with a TICI score of 0, 1 and ICA/M1 occlusion at baseline were included in this analysis. A blinded reader assigned a collateral score using a previously described 5 point scale, from 0 (no collateral flow) to 4 (complete/rapid collaterals to entire ischemic territory). Analysis was dichotomized to poor flow (0-2) versus good flow (3-4). Collateral score was correlated with baseline NIHSS, DWI volume, PWI volume (Tmax > 6), TICI reperfusion, infarct growth and mRS at day 90. Results: Sixty patients had TICI 0, 1 ICA/M1 occlusions and adequate angiographic images to evaluate collaterals. Baseline NIHSS correlated with collateral score (p=0.002). Median NIHSS for patients with poor collateral flow (0-2) was 18 (IQR, 13-22) versus 14 (10-17) for those with good flow (3-4), p=0.025. Baseline T max > 6 volume correlated with collateral score (p=0.002). Median volume of tissue at risk (T max > 6) in those with poor collateral flow was 115 ml (IQR, 74-136) versus 82 (51-109) with good flow, p=0.012. Collateral score did not correlate with baseline DWI volume. TICI reperfusion (0-3) correlated with collateral score (p=0.027). Patients with poor collateral flow had 29% TICI 2b-3 reperfusion versus 65.5% with good flow, p=0.009. Those with poor reperfusion (TICI 0-2a) showed a trend to more infarct growth with poor collaterals, 92 ml (52-194) [mean (IQR)] versus 36 ml (14-106) with good collaterals, p=0.06. Patients with poor collaterals who reperfused (TICI 2b-3) were still likely to have a mRS 0-2 at 90 days compared to those without reperfusion; OR 12 (95% CI, 1.6-98). Conclusion: Collaterals correlate with baseline clinical stroke severity and the PWI volume. In addition, good collaterals correlate with higher rates of reperfusion (TICI 2b-3). When patients do not reperfuse, good collaterals appear to limit infarct growth.

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

scholarly journals The Infarct Core is Well Represented by the Acute Diffusion Lesion: Sustained Reversal is Infrequent

2011 ◽  
Vol 32 (1) ◽  
pp. 50-56 ◽  
Author(s):  
Bruce CV Campbell ◽  
Archana Purushotham ◽  
Soren Christensen ◽  
Patricia M Desmond ◽  
Yoshinari Nagakane ◽  
...  
Keyword(s):  
Normal Brain ◽  
Lesion Volume ◽  
Infarct Core ◽  
Imaging Evaluation ◽  
Echoplanar Imaging ◽  
Median Volume ◽  
Stroke Evolution ◽  
Evaluation Trial ◽  
The Impact

Diffusion-weighted imaging (DWI) is commonly used to assess irreversibly infarcted tissue but its accuracy is challenged by reports of diffusion lesion reversal (DLR). We investigated the frequency and implications for mismatch classification of DLR using imaging from the EPITHET (Echoplanar Imaging Thrombolytic Evaluation Trial) and DEFUSE (Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution) studies. In 119 patients (83 treated with IV tissue plasminogen activator), follow-up images were coregistered to acute diffusion images and the lesions manually outlined to their maximal visual extent in diffusion space. Diffusion lesion reversal was defined as voxels of acute diffusion lesion that corresponded to normal brain at follow-up (i.e., final infarct, leukoaraiosis, and cerebrospinal fluid (CSF) voxels were excluded from consideration). The appearance of DLR was visually checked for artifacts, the volume calculated, and the impact of adjusting baseline diffusion lesion volume for DLR volume on perfusion-diffusion mismatch analyzed. Median DLR volume reduced from 4.4 to 1.5 mL after excluding CSF/leukoaraiosis. Visual inspection verified 8/119 (6.7%) with true DLR, median volume 2.33 mL. Subtracting DLR from acute diffusion volume altered perfusion—diffusion mismatch ( Tmax>6 seconds, ratio>1.2) in 3/119 (2.5%) patients. Diffusion lesion reversal between baseline and 3 to 6 hours DWI was also uncommon (7/65, 11%) and often transient. Clinically relevant DLR is uncommon and rarely alters perfusion—diffusion mismatch. The acute diffusion lesion is generally a reliable signature of the infarct core.

CT angiography-based collateral flow and time to reperfusion are strong predictors of outcome in endovascular treatment of patients with stroke

2016 ◽  
Vol 9 (10) ◽  
pp. 940-943 ◽  
Author(s):  
Fabrizio Sallustio ◽  
Caterina Motta ◽  
Silvia Pizzuto ◽  
Marina Diomedi ◽  
Angela Giordano ◽  
...  
Keyword(s):  
Ct Angiography ◽  
Mechanical Thrombectomy ◽  
Collateral Flow ◽  
Large Artery ◽  
Anterior Circulation ◽  
Conventional Angiography ◽  
Multivariable Analyses ◽  
Relationship Of ◽  
The Relationship

BackgroundCollateral flow (CF) is an effective predictor of outcome in acute ischemic stroke (AIS) with potential to sustain the ischemic penumbra. However, the clinical prognostic value of CF in patients with AIS undergoing mechanical thrombectomy has not been clearly established. We evaluated the relationship of CF with clinical outcomes in patients with large artery anterior circulation AIS treated with mechanical thrombectomy.MethodsBaseline collaterals of patients with AIS (n=135) undergoing mechanical thrombectomy were independently evaluated by CT angiography (CTA) and conventional angiography and dichotomized into poor and good CF. Multivariable analyses were performed to evaluate the predictive effect of CF on outcome and the effect of time to reperfusion on outcome based on adequacy of the collaterals.ResultsEvaluation of CF was consistent by both CTA and conventional angiography (p<0.0001). A higher rate of patients with good collaterals had good functional outcome at 3-month follow-up compared with those with poor collaterals (modified Rankin Scale (mRS) 0–2: 60% vs 10%, p=0.0001). Patients with poor collaterals had a significantly higher mortality rate (mRS 6: 45% vs 8%, p=0.0001). Multivariable analyses showed that CF was the strongest predictor of outcome. Time to reperfusion had a clear effect on favorable outcome (mRS ≤2) in patients with good collaterals; in patients with poor collaterals this effect was only seen when mRS ≤3 was considered an acceptable outcome.ConclusionsCTA is a valid tool for assessing the ability of CF to predict clinical outcome in patients with AIS treated with mechanical thrombectomy. Limiting time to reperfusion is of definite value in patients with good collaterals and also to some extent in those with poor collaterals.

Abstract W P44: Predicting Omni-directional Lesion Growth in Acute Stroke using Multimodal Intensity Profiles

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Fabien Scalzo ◽  
Wahid Chowdhury ◽  
David S Liebeskind
Keyword(s):  
Acute Stroke ◽  
Specific Model ◽  
Infarct Core ◽  
Directional Growth ◽  
Single Input ◽  
Lesion Growth ◽  
Tissue Recovery ◽  
First Time ◽  
The Relationship

Introduction: Mechanisms of lesion growth in acute stroke remain poorly characterized. Favorable imaging signatures related to regional tissue status may be disclosed with diffusion-weighted (DWI) and perfusion-weighted (PWI) imaging. Certain values of individual parameters, such as prolonged and decreased CBF, are associated with poor tissue recovery, yet scant data are available regarding the directionality of lesion growth and how different perfusion imaging parameters may be combined to best characterize lesion growth. We developed a probabilistic model that exploits DWI and multi-parametric PWI to predict likelihood of lesion growth in every 3D direction. Hypothesis: We test the hypothesis that combined intensity profiles of PWI features predict the likelihood of lesion growth, in every direction. Methods: Retrospective analysis of DWI and PWI acquired within 24 hours of symptom onset with FLAIR sequences acquired four days later. DWI and PWI were co-registered and the lesions were manually delineated on the baseline DWI and follow-up FLAIR. Intensity profiles of perfusion parameters (including CBV, CBF, MTT, TTP, Tmax) were extracted along discrete spherical coordinates (every 5 degrees). A nonlinear regression model was used to capture the relationship between the intensity profile along a direction and the amount of growth in that direction. A cross-validation was performed to evaluate the accuracy of the model in predicting the lesion growth in every direction at day 4. Results: A total of 49 patients were included in the analysis. Mean age was 68.7 (35-91). Median baseline NIHSS was 16 (2-31) and median mRS at discharge was 5 (1-6). Lowest prediction error (62 cm2 IQR [26 86]) in terms of average lesion surface and final directional growth error 7.91 mm IQR [5.2 10.3] was obtained by combining cBV, cBF, TTP, TMAX intensity profiles into a single input vector. Conclusions: For the first time, a direction-specific model of infarct growth has been developed. It provides quantitative insights about the likelihood of lesion growth surrounding a stroke. This prediction is not only based on closeness to the infarct core or the presence of penumbra but relies also on the complex dependencies between joint evidence found in multiple perfusion parameters.

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.

Relationship of Volume of Lesion to Length of Hospital Stay and Outcome at One Year in Stroke Patients

2001 ◽  
Vol 46 (6) ◽  
pp. 178-183 ◽  
Author(s):  
J.M. Maddox ◽  
R.S. MacWalter ◽  
A.D. McMahon
Keyword(s):  
Hospital Stay ◽  
Functional Outcome ◽  
Univariate Analysis ◽  
Length Of Hospital Stay ◽  
Lesion Volume ◽  
Functional Outcome Measures ◽  
One Year ◽  
Relationship Of ◽  
The Relationship

The aim of this study was to investigate the relationship between the volume of lesion (VOL) in patients with stroke and the associated length of hospital stay (LOS), as well as longer-term functional outcome. Computerised tomography (CT) scans were used to measure the volume, region and type of lesion, volume being measured by planimetry. LOS and other patient details were obtained from the Dundee Stroke Database. The total LOS was associated with the VOL on univariate analysis (p=0.004) and after adjustment for the other variables (p-0.006) due to a larger lesion being associated with longer stay in hospital. Patient follow-up confirmed that the VOL was also highly significant when related to functional outcome measures of impairment, disability and handicap at one year, as determined by Orgogozo (p=0.03), Barthel (p<0.01) and Rankin scores (p<0.01) respectively. The VOL is related to the length of stay in hospital and outcome at one year. This is of particular interest with the increasing use of thrombolysis and development of neuroprotectant agents designed to limit VOL.

scholarly journals Prognostic Value of Perfusion MR Imaging of High-Grade Astrocytomas: Long-Term Follow-Up Study

2008 ◽  
Vol 29 (8) ◽  
pp. 1505-1510 ◽  
Author(s):  
T. Hirai ◽  
R. Murakami ◽  
H. Nakamura ◽  
M. Kitajima ◽  
H. Fukuoka ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Prognostic Value ◽  
High Grade ◽  
Follow Up Study ◽  
Long Term Follow Up ◽  
Perfusion Mr ◽  
Perfusion Mr Imaging

Abstract W P24: Choice of Thrombectomy Device and Degree of Collateral Flow Predict Reperfusion in DEFUSE 2

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
John T Liggins ◽  
Michael Mlynash ◽  
Matus Straka ◽  
Stephanie Kemp ◽  
Roland Bammer ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Artery Occlusion ◽  
Collateral Flow ◽  
Stroke Patients ◽  
Ischemic Brain ◽  
Factors Associated ◽  
Thrombectomy Device ◽  
Stent Retrievers ◽  
The Relationship ◽  
Univariate Analyses

Background: Endovascular therapy for acute ischemic stroke is an effective tool for recanalizing occluded vessels. We sought to determine the factors associated with successful reperfusion and whether any differences in reperfusion rates existed between hospital sites. Methods: Stroke patients underwent endovascular treatment as part of the DEFUSE 2 study at nine hospital sites between 2008 and 2011. Patients were included for analysis if they had a baseline TICI score of 0 or 1. Successful reperfusion was defined as a TICI reperfusion score of 2b or 3 at the completion of the procedure. Collaterals were assessed using the Collateral Flow Grading System and were dichotomized as poor (0-2) or good (3-4). The relationship between clinical, neuroimaging and treatment variables and TICI reperfusion was assessed using logistic regression. Results: Eighty-nine patients had a baseline TICI score of 0 or 1; thirty-six patients achieved successful TICI reperfusion. Patients were treated with the Merci clot retriever (n=25), the Penumbra device (n=19), both Merci and Penumbra (n=17), or other endovascular therapies (n=28). Other interventions included manual aspiration (n=20), stent retrievers (n=7) and angioplasty (n=7). Variables associated with successful reperfusion in univariate analyses were: good collaterals (p<0.01), location of artery occlusion (p<0.05), use of the Merci retriever (p<0.01), and hospital site (p<0.01). In multivariate analysis, good collaterals (p<0.01) and use of the Merci retriever (p<0.05) remained as independent predictors of successful reperfusion. Conclusion: In acute stroke patients who undergo endovascular therapy, good collateral flow to the ischemic brain region and use of the Merci retriever are associated with successful reperfusion. The rates of successful reperfusion differed between hospital sites. This may have been driven by variation in the rates of use of the Merci retriever.

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