Abstract T P25: Poor Collaterals Necessitate Early Reperfusion: Relationship Between Time to Reperfusion, Collateral Flow, and Clinical Outcome

Background: Clinical outcome following reperfusion can be affected by the adequacy of baseline collaterals during endovascular therapy. We examined the relationship between onset-to-reperfusion time (ORT), collateral grade, and clinical outcome with the hypothesis that there is a narrow therapeutic time window for good clinical outcomes in patients having poor collaterals. Methods: Among 300 patients who underwent endovascular therapy for acute large vessel occlusion in the anterior circulation, we identified 220 patients having a final TICI score of 2 or more. Patients’ collateral grades, using the ASITN/SIR scale on baseline angiography, were dichotomized into poor (0-1) versus partial/complete (2-4). Favorable functional outcome was defined as a 3-month mRS of 0-2. Results: Angiographic data on collaterals were available for 207/220 patients, with 76 in the poor collateral group and 131 in the partial/complete group. The TICI 2b-3 reperfusion rates were similar between the two groups [51/76 (67%) vs. 89/131 (68%), p=0.902], though functional outcomes were significantly different [35/76 (46%) vs. 81/131 (63%), p=0.027]. In the poor collateral group, the odds of favorable outcome significantly dropped for patients reperfused beyond 6-hour from onset [28/53 (54%) vs. 7/24 (29%); odds ratio 0.35 (95% CI 0.13-0.99); p=0.045], whereas the probability of favorable outcome in partial/complete group was not as influenced by reperfusion beyond the 6-hour time window [56/85 (66%) vs. 25/46 (54%); odds ratio 0.62 (95% CI 0.30-1.29); p=0.195]. In subgroup analysis of the poor collateral group, each 30-minute increase in ORT was associated with a decreased chance of favorable outcome despite reperfusion after adjustment for age, baseline NIHSS score, and baseline ASPECTS score [odds ratio 0.77 (95% CI 0.64-0.93); p=0.006]. Conclusions: Onset-to-reperfusion time in patients with poor collaterals is an another important factor affecting favorable outcome, and future trials would benefit from a non-invasive imaging technique to detect poor collaterals along with a strategy for early reperfusion.

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Abstract TMP1: Distal Hyperintense Vessels Score on Flair is a Marker of Collateral Flow Grade and Outcomes in Patients with Acute Ischemic Stroke After Endovascular Therapy

Stroke ◽

10.1161/str.48.suppl_1.tmp1 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Masatomo Miura ◽

Makoto Nakajima ◽

Takuya Kanamaru ◽

Kazutaka Uchida ◽

Manabu Shirakawa ◽

...

Keyword(s):

Clinical Outcome ◽

Endovascular Therapy ◽

Cerebral Angiography ◽

Favorable Outcome ◽

Stroke Severity ◽

Collateral Flow ◽

Flair Sequence ◽

Inversion Recovery Imaging ◽

Fluid Attenuated Inversion Recovery ◽

American Society

Background: Distal hyperintense vessels (DHV) on fluid-attenuated inversion recovery imaging (FLAIR) is a noninvasive and useful imaging marker that reflects leptomeningeal collateral flow. We investigated relationship between DHV and collateral grade on cerebral angiography, and clinical outcome after endovascular therapy (EVT) in patients with AIS. Methods: We retrospectively analyzed the patients with AIS in two comprehensive stroke centers from October 2013 to February 2016. We selected the patients who underwent FLAIR sequence before EVT. DHV score (range 0-6) was evaluated based on the presence of DHV in each ASPECTS territory (M1-M6). Collateral grades on cerebral angiography were assessed with the American Society of Interventional and Therapeutic Neuroradiology Collateral Grading System (grade 0-4). Favorable clinical outcomes was defined as modified Rankin Scale [mRS] of 0-2 at 90 days. Results: A total of 60 patients (aged 71.2 ± 10.5 years; initial NIHSS score, 15 ± 8; median DWI-ASPECTS, 7) were included. DHV was detected in 42 patients (70%); median DHV score was 2 (IQR, 1-4). Higher DHV score was significantly related to better collateral flow grade ( p <0.001), and favorable outcome ( p <0.001). In multivariate analysis, DHV score predicted favorable outcome (OR 2.83 per 1 point; 95% CI 1.71-5.48; p <0.001), independent of stroke severity or successful reperfusion. Conclusions: DHV score on FLAIR is a marker of collateral flow status and can predict better clinical outcome in patients with AIS after EVT.

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Good Clinical Outcome Decreases With Number of Retrieval Attempts in Stroke Thrombectomy

Stroke ◽

10.1161/strokeaha.120.029830 ◽

2021 ◽

Vol 52 (2) ◽

pp. 482-490

Author(s):

Fabian Flottmann ◽

Caspar Brekenfeld ◽

Gabriel Broocks ◽

Hannes Leischner ◽

Rosalie McDonough ◽

...

Keyword(s):

Clinical Outcome ◽

Cerebral Infarction ◽

Scale Score ◽

Endovascular Therapy ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Functional Independence ◽

Good Clinical Outcome ◽

Anterior Circulation ◽

Vessel Occlusion

Background and Purpose: Endovascular therapy is the standard of care in the treatment of acute ischemic stroke due to large-vessel occlusion. Often, more than one retrieval attempt is needed to achieve reperfusion. We aimed to quantify the influence of endovascular therapy on clinical outcome depending on the number of retrievals needed for successful reperfusion in a large multi-center cohort. Methods: For this observational cohort study, 2611 patients from the prospective German Stroke Registry included between June 2015 and April 2018 were analyzed. Patients who received endovascular therapy for acute anterior circulation stroke with known admission National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score, final Thrombolysis in Cerebral Infarction score, and number of retrievals were included. Successful reperfusion was defined as a Thrombolysis in Cerebral Infarction score of 2b or 3. The primary outcome was defined as functional independence (modified Rankin Scale score of 0–2) at day 90. Multivariate mixed-effects models were used to adjust for cluster effects of the participating centers and confounders. Results: The inclusion criteria were met by 1225 patients. The odds of good clinical outcome decreased with every retrieval attempt required for successful reperfusion: the first retrieval had the highest odds of good clinical outcome (adjusted odds ratio, 6.45 [95% CI, 4.0–10.4]), followed by the second attempt (adjusted odds ratio, 4.56 [95% CI, 2.7–7.7]), and finally the third (adjusted odds ratio, 3.16 [95% CI, 1.8–5.6]). Conclusions: Successful reperfusion within the first 3 retrieval attempts is associated with improved clinical outcome compared with patients without reperfusion. We conclude that at least 3 retrieval attempts should be performed in endovascular therapy of anterior circulation strokes. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03356392.

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Abstract P499: The Effect of Small Vessel Disease Burden on Core/Penumbra Mismatch and Outcomes in Extended Window Thrombectomy

Stroke ◽

10.1161/str.52.suppl_1.p499 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Destiny Hooper ◽

Tariq Nisar ◽

Meryim Poursheykhi ◽

Andy Lin ◽

C. David McCane ◽

...

Keyword(s):

White Matter ◽

Perfusion Imaging ◽

Functional Outcomes ◽

Time Window ◽

Small Vessel Disease ◽

Small Vessel ◽

Collateral Flow ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Vessel Disease

Objective: Recent studies have shown the benefit of revascularization in select patients with extended window large vessel occlusion (EWLVO). We sought to assess the effect of cerebral small vessel disease (CSVD) burden on eligibility for intervention with mechanical thrombectomy (MT) and functional outcomes in patients with EWLVO. Methods: We conducted a retrospective single-center study of 135 patients with anterior circulation LVO who presented in the extended time window, 6 to 24 hours from LKW, between August 2018 and March 2020. All patients underwent perfusion imaging at initial presentation and those with target ischemic core to penumbra mismatch profiles, as defined by DAWN/DEFUSE3 criteria, were treated with MT. Included patients were evaluated for CSVD burden using T2-FLAIR MRI. The Fazekas scale (0-3) was used to quantify the amount of white matter T2 hyperintense lesions in both the periventricular (PVWM) and deep white matter (DWM). Patients’ functional outcomes were assessed at 90 days using the mRS. Multivariate ordinal logistic regression models were used and adjusted for age, gender, thrombus location and LKW to perfusion imaging time. Patient information was collected from the Houston Methodist Hospital Outcomes Based Prospective Endpoints in Stroke (HOPES) registry. Results: Of the 135 patients, 111 met imaging inclusion criteria for revascularization with MT for EWLVO. MT was deferred in 44 of these patients due to other clinical exclusions or patient refusal. Patients ineligible for MT were approximately 13 times more likely to have a higher PVWM Fazekas grade (OR =13.53, 95% CI. [2.94 - 62.39], p=0.001) and 17 times more likely to have a higher DWM Fazekas grade (OR =17.54, 95% CI. [4.20 - 73.17], p<0.001), when compared to patients who were eligible for MT. Patients who did not meet criteria for MT were nearly 7 times more likely to have poor functional outcomes at 90 days (OR =6.85, 95% CI. [2.09 - 22.44], p=0.001). Conclusion: Based on our analytical cohort of EWLVO patients, those with severe CSVD burden were more likely to be excluded from MT and had worse functional outcomes. Poor cerebrovascular reserve and diminished collateral flow leading to rapid infarct progression in patients with greater CSVD burden may be a potential explanation.

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Abstract 3183: Prognosis of Mild Ischemic Stroke with Large Vessel Occlusion

Stroke ◽

10.1161/str.43.suppl_1.a3183 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Esteban Cheng-Ching ◽

Russell Cerejo ◽

Ken Uchino ◽

Muhammad S Hussain ◽

Gabor Toth

Keyword(s):

Ischemic Stroke ◽

Endovascular Therapy ◽

Time Window ◽

Optimal Treatment ◽

Large Vessel ◽

Stroke Severity ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score ◽

Mild Stroke

Background and purpose Large vessel occlusion (LVO) in acute ischemic stroke has been reported to be an independent predictor of unfavorable clinical outcome. However, the prognosis and optimal treatment of patients with only mild neurologic deficits due to LVO are not known. Methods We performed a retrospective chart review from a database of stroke patients admitted to our large academic medical center between July 1, 2010 and June 30 , 2011. Inclusion criteria were acute stroke or TIA, presentation within 9 hours from symptom onset, large vessel occlusion as a culprit of ischemic symptoms, and mild stroke severity with initial NIH Stroke Scale (NIHSS) score <8. Results We identified 59 patients with mild ischemic stroke or TIA, who were evaluated within 9 hours from onset. Of these, 13 (22%) had culprit large vessel occlusions. Five were female, 1 had diabetes, 12 had hypertension, 7 had hyperlipidemia, 2 had atrial fibrillation and 7 were smokers. The median NIHSS score was 5. The location of arterial occlusions were 5 in M1 segment of the middle cerebral artery (MCA), 6 in M2 segment of MCA, 1 each in posterior cerebral and vertebral arteries. Two patients received acute therapy, 1 with intravenous thrombolysis and 1 with endovascular therapy. Reasons for withholding thrombolytic therapy were time window in 8, mild stroke severity in 2, and atypical presentations in 2. Reasons for withholding acute endovascular therapy were mild stroke severity in 7, imaging finding in 2, technical considerations in 2, and lack of consent in 1. From hospital admission to discharge, 10 (77%) patients had symptom improvement, 2 had worsening, and one was unchanged. At 30 days, 5 (38%) had good outcome with a modified Rankin Scale (mRS) of 0-1. Three (23%) had mRS of 2, one (8%) patient had mRS of 3. Outcomes for 4 patients were unknown. Conclusions A significant proportion of patients presenting with mild ischemic symptoms has large vessel occlusion. Acute treatment in this population is frequently withheld due to mild severity or thrombolytic time window. Despite mild symptoms at presentation, some patients are left with moderate disability. Optimal treatment options for this population should be further evaluated in a larger group of patients.

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Acute Recanalization of Thrombo-Embolic Ischemic Stroke with pREset (ARTESp): the impact of occlusion time on clinical outcome of directly admitted and transferred patients

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2016-012556 ◽

2016 ◽

Vol 9 (9) ◽

pp. 817-822 ◽

Cited By ~ 16

Author(s):

Sascha Prothmann ◽

Benedikt J Schwaiger ◽

Alexandra S Gersing ◽

Wolfgang Reith ◽

Thomas Niederstadt ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Favorable Outcome ◽

Vessel Occlusion ◽

Critical Determinant ◽

Occlusion Time ◽

Intracranial Vessel ◽

Registration Number ◽

Multivariable Regression ◽

The Impact

ObjectivesAcute Recanalization of Thrombo-Embolic Ischemic Stroke with pREset (ARTESp) is a prospective multicenter study assessing the efficacy and safety of the pREset stent retriever for the treatment of intracranial vessel occlusion. Determination of the effect of transfer status on clinical outcome was a secondary objective.MethodsEfficacy was measured by recanalization success (Thrombolysis in Cerebral Infarction score ≥2b) and favorable clinical outcome at 90 days (modified Rankin Scale 0–2). Intracranial hemorrhage (ICH) and death at 90 days were safety measures. The outcome of directly admitted (DAP) and transferred (TP) patients was investigated using multivariable regression models.ResultsFour study centers included 100 patients (mean age 68.3 years, median National Institutes of Health Stroke Scale score 15). Recanalization success was achieved in 84.4% after a mean of 1.7 passes. ICH was detected in 14.0%, with 2.0% being symptomatic. At 90 days, 62.5% of the patients had a favorable outcome and 7.3% died. TP had longer occlusion times (289 vs 180 minutes, p<0.001) and a lower rate of favorable outcome (58.0% vs 78.4%, p=0.046) than DAP. Multivariable regression revealed occlusion time as the critical determinant (OR=0.963, 95% CI 0.931 to 0.997, p=0.032), whereas transfer status itself showed no significant association (OR=0.565, CI 0.133 to 2.393, p=0.438).ConclusionspREset proved to be safe and effective for the treatment of acute intracranial vessel occlusion. Increased occlusion time impaired clinical outcome in TP.Trial registration numberNCT02437409; Results.

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Leptomeningeal Collateral Flow Modifies Endovascular Treatment Efficacy on Large-Vessel Occlusion Strokes

Stroke ◽

10.1161/strokeaha.120.031338 ◽

2021 ◽

Vol 52 (1) ◽

pp. 299-303

Author(s):

Álvaro García-Tornel ◽

Ludovico Ciolli ◽

Marta Rubiera ◽

Manuel Requena ◽

Marian Muchada ◽

...

Keyword(s):

Ct Angiography ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Multivariable Analysis ◽

Large Vessel ◽

Collateral Flow ◽

Vessel Occlusion ◽

Shift Analysis ◽

Final Degree ◽

Large Vessel Stroke

Background and Purpose: We aim to evaluate if good collateral flow (CF) modifies endovascular therapy (EVT) efficacy on large-vessel stroke. To do that, we used final degree of reperfusion and number of device-passes performed, factors previously associated with better functional outcome, as main outcome measures. Methods: Single-center retrospective study including consecutive stroke patients receiving EVT for anterior circulation large-vessel stroke. CF degree was assessed on CT angiography before EVT using a previously validated 4-grade score. Final degree of reperfusion, using modified Thrombolysis in Cerebral Ischemia (mTICI), and number of device-passes performed were prospectively collected. Multivariable analysis was performed to evaluate the influence of collateral flow degree on final degree of reperfusion and number of device-passes performed. Results: Six hundred twenty-six patients were included in the study; 369 patients (59%) presented good collateral flow on CT angiography. Five hundred twenty-two patients (84%) achieved successful reperfusion (mTICI 2B-3) after EVT, 304 (48%) of them with a final mTICI 2C-3. Median number of device-passes was 2 (interquartile range, 1–3). Good CF was independently associated with better final degree of reperfusion (shift analysis for mTICI0-2A/2B/2C-3%, poor CF 19/38/43 versus good CF 15/32/53, adjusted odds ratio, 1.51 [95% CI, 1.08–2.11]). Poor CF was independently associated with higher number of device-passes performed to achieve successful reperfusion (mTICI2B-3; shift analysis for 1/2/3/4+ device-passes, adjusted odds ratio, 1.59, [95% CI, 1.09–2.31]) and complete reperfusion (mTICI2C-3; shift analysis for 1/2/3/4+ device-passes, adjusted odds ratio, 1.70 [95% CI, 1.04–2.90]). Conclusions: Patients with good CF treated with EVT experience higher rates of successful reperfusion with lower number of device-passes. CF may facilitate thrombus retrieval and prevent distal embolization of clot fragments, improving device-passes efficacy.

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Thrombolysis Improves Reperfusion and the Clinical Outcome in Tandem Occlusion Stroke Related to Cervical Dissection: TITAN and ETIS Pooled Analysis

Journal of Stroke ◽

10.5853/jos.2020.04889 ◽

2021 ◽

Vol 23 (3) ◽

pp. 411-419

Author(s):

Gaultier Marnat ◽

Igor Sibon ◽

Romain Bourcier ◽

Mohammad Anadani ◽

Florent Gariel ◽

...

Keyword(s):

Clinical Outcome ◽

Odds Ratio ◽

Intravenous Thrombolysis ◽

Pooled Analysis ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Excellent Outcome ◽

Shift Analysis ◽

Tandem Occlusion ◽

Symptomatic Intracranial Hemorrhage

Background and Purpose Despite the widespread adoption of mechanical thrombectomy (MT) for the treatment of large vessel occlusion stroke (LVOS) in the anterior circulation, the optimal strategy for the treatment tandem occlusion related to cervical internal carotid artery (ICA) dissection is still debated. This individual patient pooled analysis investigated the safety and efficacy of prior intravenous thrombolysis (IVT) in anterior circulation tandem occlusion related to cervical ICA dissection treated with MT.Methods We performed a retrospective analysis of two merged prospective multicenter international real-world observational registries: Endovascular Treatment in Ischemic Stroke (ETIS) and Thrombectomy In TANdem occlusions (TITAN) registries. Data from MT performed in the treatment of tandem LVOS related to cervical ICA dissection between January 2012 and December 2019 at 24 comprehensive stroke centers were analyzed. The primary endpoint was a favorable outcome defined as 90-day modified Rankin Scale (mRS) score of 0–2.Results The study included 144 patients with tandem occlusion LVOS due to cervical ICA dissection, of whom 94 (65.3%) received IVT before MT. Prior IVT was significantly associated with a better clinical outcome considering the mRS shift analysis (common odds ratio, 2.59; 95% confidence interval [CI], 1.35 to 4.93; P=0.004 for a 1-point improvement) and excellent outcome (90-day mRS 0–1) (adjusted odds ratio [aOR], 4.23; 95% CI, 1.60 to 11.18). IVT was also associated with a higher rate of intracranial successful reperfusion (83.0% vs. 64.0%; aOR, 2.70; 95% CI, 1.21 to 6.03) and a lower rate of symptomatic intracranial hemorrhage (4.3% vs. 14.8%; aOR, 0.21; 95% CI, 0.05 to 0.80).Conclusions Prior IVT before MT for the treatment of tandem occlusion related to cervical ICA dissection was safe and associated with an improved 90-day functional outcome.

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Safety and Outcome of Carotid Dissection Stenting During the Treatment of Tandem Occlusions

Stroke ◽

10.1161/strokeaha.120.030038 ◽

2020 ◽

Vol 51 (12) ◽

pp. 3713-3718 ◽

Cited By ~ 1

Author(s):

Gaultier Marnat ◽

Bertrand Lapergue ◽

Igor Sibon ◽

Florent Gariel ◽

Romain Bourcier ◽

...

Keyword(s):

Ischemic Stroke ◽

Carotid Artery ◽

Endovascular Therapy ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Favorable Outcome ◽

Sensitivity Analyses ◽

Carotid Dissection ◽

Symptomatic Intracerebral Hemorrhage ◽

Tandem Occlusion

Background and Purpose: The efficacy of endovascular therapy in patients with acute ischemic stroke due to tandem occlusion is comparable to that for isolated intracranial occlusion in the anterior circulation. However, the optimal management of acute cervical internal carotid artery lesions is unknown, especially in the setting of carotid dissection, but emergency carotid artery stenting (CAS) is frequently considered. We investigated the safety and efficacy of emergency CAS for carotid dissection in patients with acute stroke with tandem occlusion in current clinical practice. Methods: We retrospectively analyzed a prospectively maintained database composed of 2 merged multicenter international observational real-world registries (Endovascular Treatment in Ischemic Stroke and Thrombectomy in Tandem Lesion). Data from endovascular therapy performed in the treatment of tandem occlusions related to acute cervical carotid dissection between January 2012 and January 2019 at 24 comprehensive stroke centers were analyzed. Results: The study assessed 136 patients with tandem occlusion due to dissection, including 65 (47.8%) treated with emergency CAS and 71 (52.2%) without. The overall rates of favorable outcome (90-day modified Rankin Scale score, 0–2) and successful reperfusion (modified Thrombolysis in Cerebral Infarction, 2b–3) were 58.0% (n=76 [95% CI, 49.6%–66.5%]) and 77.9% (n=106 [95% CI, 71.0%–85.0%]), respectively. In subgroup analyses, the rate of successful reperfusion (89.2% versus 67.6%; adjusted odds ratio, 2.24 [95% CI, 1.33–3.77]) was higher after CAS, whereas the 90-day favorable outcome (54.3% versus 61.4%; adjusted odds ratio, 0.84 [95% CI, 0.58–1.22]), symptomatic intracerebral hemorrhage (sICH; 10.8% versus 5.6%; adjusted odds ratio, 1.59 [95% CI, 0.79–3.17]), and 90-day mortality (8.0% versus 5.8%; adjusted odds ratio, 1.00 [95% CI, 0.48–2.09]) did not differ. In sensitivity analyses of patients with successful intracranial reperfusion, CAS was not associated with an improved clinical outcome. Conclusions: Emergency stenting of the dissected cervical carotid artery during endovascular therapy for tandem occlusions seems safe, whatever the quality of the intracranial reperfusion.

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Impact of Antiplatelet Therapy During Endovascular Therapy for Tandem Occlusions

Stroke ◽

10.1161/strokeaha.119.028231 ◽

2020 ◽

Vol 51 (5) ◽

pp. 1522-1529 ◽

Cited By ~ 8

Author(s):

François Zhu ◽

Mohammad Anadani ◽

Julien Labreuche ◽

Alejandro Spiotta ◽

Francis Turjman ◽

...

Keyword(s):

Carotid Artery ◽

Antiplatelet Therapy ◽

Endovascular Therapy ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

De Novo ◽

Antiplatelet Agent ◽

Favorable Outcome ◽

Anterior Circulation ◽

The Impact

Background and Purpose— Antiplatelet agents could be used in the setting of endovascular therapy for tandem occlusions to reduce the risk of de novo intracranial embolic migration, reocclusion of the extracranial internal carotid artery lesion, or in-stent thrombosis in case of carotid stent placement but have to be balanced with the intracerebral hemorrhagic transformation risk. In this study, we aim to investigate the impact of acute antiplatelet therapy administration on outcomes during endovascular therapy for anterior circulation tandem occlusions. Methods— This is a retrospective analysis of a collaborative pooled analysis of 11 prospective databases from the multicenter observational TITAN registry (Thrombectomy in Tandem Lesions). Patients were divided into groups based on the number of antiplatelet administered during endovascular therapy. The primary outcome was favorable outcome, defined as a modified Rankin Scale score of 0 to 2 at 90 days. Results— This study included a total of 369 patients; 145 (39.3%) did not receive any antiplatelet agent and 224 (60.7%) received at least 1 antiplatelet agent during the procedure. Rate of favorable outcome was nonsignificantly higher in patients treated with antiplatelet therapy (58.3%) compared with those treated without antiplatelet (46.0%; adjusted odds ratio, 1.38 [95% CI, 0.78–2.43]; P =0.26). Rate of 90-day mortality was significantly lower in patients treated with antiplatelet therapy (11.2% versus 18.7%; adjusted odds ratio, 0.47 [95% CI, 0.22–0.98]; P =0.042), without increasing the risk of any intracerebral hemorrhage. Successful reperfusion (modified Thrombolysis in Cerebral Ischemia score 2b-3) rate was significantly better in the antiplatelet therapy group (83.9% versus 71.0%; adjusted odds ratio, 1.89 [95% CI, 1.01–3.64]; P =0.045). Conclusions— Administration of antiplatelet therapy during endovascular therapy for anterior circulation tandem occlusions was safe and was associated with a lower 90-day mortality. Optimal antiplatelet therapy remains to be assessed, especially when emergent carotid artery stenting is performed. Further randomized controlled trials are needed.

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Quantitative Lesion Water Uptake as Stroke Imaging Biomarker: A Tool for Treatment Selection in the Extended Time Window?

Stroke ◽

10.1161/strokeaha.120.033025 ◽

2021 ◽

Author(s):

Gabriel Broocks ◽

Andre Kemmling ◽

Svenja Teßarek ◽

Rosalie McDonough ◽

Lukas Meyer ◽

...

Keyword(s):

Logistic Regression ◽

Clinical Outcome ◽

Water Uptake ◽

Odds Ratio ◽

Mechanical Thrombectomy ◽

Time Window ◽

Imaging Biomarker ◽

Extended Time ◽

Ischemic Lesion ◽

Clinical Prognosis

Background and Purpose: Patients presenting in the extended time window may benefit from mechanical thrombectomy. However, selection for mechanical thrombectomy in this patient group has only been performed using specialized image processing platforms, which are not widely available. We hypothesized that quantitative lesion water uptake calculated in acute stroke computed tomography (CT) may serve as imaging biomarker to estimate ischemic lesion progression and predict clinical outcome in patients undergoing mechanical thrombectomy in the extended time window. Methods: All patients with ischemic anterior circulation stroke presenting within 4.5 to 24 hours after symptom onset who received initial multimodal CT between August 2014 and March 2020 and underwent mechanical thrombectomy were analyzed. Quantitative lesion net water uptake was calculated from the admission CT. Prediction of clinical outcome was assessed using univariable receiver operating characteristic curve analysis and logistic regression analyses. Results: One hundred two patients met the inclusion criteria. In the multivariable logistic regression analysis, net water uptake (odds ratio, 0.78 [95% CI, 0.64–0.95], P =0.01), age (odds ratio, 0.94 [95% CI, 0.88–0.99]; P =0.02), and National Institutes of Health Stroke Scale (odds ratio, 0.88 [95% CI, 0.79–0.99], P =0.03) were significantly and independently associated with favorable outcome (modified Rankin Scale score ≤1), adjusted for degree of recanalization and Alberta Stroke Program Early CT Score. A multivariable predictive model including the above parameters yielded the highest diagnostic ability in the classification of functional outcome, with an area under the curve of 0.88 (sensitivity 92.3%, specificity 82.9%). Conclusions: The implementation of quantitative lesion water uptake as imaging biomarker in the diagnosis of patients with ischemic stroke presenting in the extended time window might improve clinical prognosis. Future studies could test this biomarker as complementary or even alternative tool to CT perfusion.

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