Abstract W P8: Role of Core Infarct Volume Affecting the Number Needed to Treat in Endovascular Therapy for Acute Ischemic Stroke From Large Vessel Occlusion

Purpose: The infarct core has been hypothesized to be highly predictive of treatment effect for endovascular intervention in acute ischemic stroke from large vessel proximal occlusion. The purpose of this study was to determine how it affects the number of patients needed to treat (NNT) by this therapy to improve long term functional status. Methods: Patients with acute stroke not eligible and/or refractory to IV rtPA, treated by the Penumbra System (N=463) were pooled from various studies: Pivotal (N=83), PICS (N=174), RetroSTART (N=96) and START (N=110). They were compared with 62 control patients who were eligible for but not treated by endovascular therapy. The NNT for both groups to achieve 90 day functional independence as defined by an mRS score of ≤2 were compared. The impact of the infarct core at presentation defined by ASPECTS trichotomized as small (8-10), medium (5-7) and large (0-4) was assessed. The distribution of the infarct core (N) for Penumbra:control patients were: 257:50, 155:7 and 51:3, respectively for small, medium and large. Two control patients did not have ASPECTS scores. Results: There were no differences in baseline characteristics between the two group median values (Control;Penumbra): Age (72;68), NIHSS (18;17), ASPECTS (ASP) (9;8). There were significant differences in rate of recanalization, all-cause mortality and good functional outcome (mRS ≤2) but not symptomatic ICH (Table). The NNT to improve functional status was 5.6 for the entire cohort of treated patients, 4.7 for those with small core, 4.1 for medium and 12.8 for large. Conclusion: These data indicate that endovascular treatment may not be effective in patients with a large infarct core and could contribute to the high NNT needed to achieve long term good functional status. Eliminating this group at time of triage may significantly lower the NNT and improve the treatment effect of this therapy.

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Abstract W P14: Significant Correlation between Neurological and Functional Recoveries in the Natural History of Acute Ischemic Stroke from Large Vessel Occlusion

Stroke ◽

10.1161/str.46.suppl_1.wp14 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Vallabh Janardhan ◽

Albert J Yoo ◽

Donald F Frei ◽

Lynne Ammar ◽

Sophia S Kuo ◽

...

Keyword(s):

Ischemic Stroke ◽

Natural History ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Strong Correlation ◽

Infarct Volume ◽

Large Vessel ◽

Infarct Core ◽

Nihss Score ◽

History Of

Purpose: There have been conflicting reports on the correlation between neurological and functional recoveries in acute ischemic stroke. NIHSS and mRS scores not always correlated in patients after treatment. Since the inconsistencies could be related to the variable effectiveness of treatments, the aim of this study was to test their correlation in patients with large vessel proximal occlusion who are eligible but not treated with endovascular therapy. In addition, we analyzed the data based on trichotomized ASPECTS scores to minimize the confounding influence of the infarct core. Methods: The FIRST Trial is a prospective natural history study of a stroke cohort eligible for but untreated by endovascular therapy and ineligible or refractory to IV rtPA. NIHSS and mRS scores were measured in 93 patients at admission, 24 hour and 7 days after hospital presentation and were analyzed by logistic regression against different core infarct volume as indexed by ASPECTS scores of 8-10, 5-7, and 0-4. Results: Median admission NIHSS score was 18 (IQR 14-23, N=93). The mean and mean increase at 24 h NIHSS both showed correlations with trichotomized ASPECTS, p=0.0064 and 0.0202, respectively. NIHSS at 24 h and 7 days displayed a strong relationship with 90 day mRS 0-2 (p=0.0002, N=67; p=0.0003, N=66). NIHSS had a strong correlation to 90 day mRS scores (continuous), with high 7 day scores correlated with high mRS scores and 7 day NIHSS change negatively correlated to 90 day mRS scores (Spearman correlations, all p<0.0001). Significant correlations were seen between 24 h and 7 day NIHSS and 90 day mRS by trichotomized ASPECTS (both p=0.04275). In addition, controlling for trichotomous ASPECTS groups, 7 Day NIHSS score was the best predictor of mRS 90d 0-2 (OR= 0.717, p= 0.0018). Conclusion: These data indicate that there is a strong correlation between neurological and functional recoveries in the natural history of acute ischemic when the confounding influences of treatment and the infarct core are taken into account.

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Abstract WMP5: Endovascular Therapy Stroke Outcome in Very Elderly: Meta-analysis

Stroke ◽

10.1161/str.47.suppl_1.wmp5 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Michelle P Lin ◽

David S Liebeskind ◽

Steven Cen ◽

William J Mack ◽

Arun P Amar ◽

...

Keyword(s):

Ischemic Stroke ◽

Elderly Patients ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Endovascular Therapy ◽

Odds Ratio ◽

Age Groups ◽

Large Vessel ◽

Very Elderly

Introduction: Very elderly (age ≥80yo) individuals account for about one-third of all stroke admissions with mixed literature demonstrating relative poor stroke outcomes. With overwhelming recent evidence supporting the use of intra-arterial thrombectomy in addition to IV thrombolysis for large-vessel occlusive stroke, we conducted a metaanalysis to assess long-term functional outcome following mechanical thrombectomy in very elderly. Hypothesis: Very elderly patients with acute ischemic stroke treated with thrombectomy have equally favorable long-term functional outcomes to their younger counterparts Methods: Stroke endovascular trials published in New England Journal of Medicine 2014-2015 were included if they reported odds ratio of good functional outcome (improvement in modified Rankin score, mRS) comparing thrombectomy vs IV-tPA dichotomized by age groups (age ≤ 80yo vs >80yo, 2 studies dichotomized age at 70yo). Multivariate adjusted odds ratios and the corresponding standard errors were used for the metaanalysis. Pooled odds ratio estimates across trials were synthesized by using a random-effects model based on Mantel-Haenszel methods. The pooled estimates with 95% confidence interval were compared between elderly and younger age groups. Forest plots constructed. Results: Of the 5 recent intraartrial thrombectomy trials, 4 studies reported subgroup analysis by age with 1,206 participants, 28% (N=334) were above the age of 80yo, 72% (N=872) were ≤80yo. Among very elderly patients undergoing thrombectomy, the pooled odds ratio of good functional outcome at 3 months was 1.91 (1.13-3.24), in the younger group the pooled odds ratio was 1.95 (1.50-2.53). Conclusions: Endovascular therapy was an effective therapy for very elderly individuals presenting with acute ischemic stroke caused by large vessel occlusive disease. Future studies are needed to further assess the safety and effectiveness of thrombectomy in this growing population.

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Prevalence of large vessel occlusion in patients presenting with acute ischemic stroke: a 10-year systematic review of the literature

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014239 ◽

2018 ◽

Vol 11 (3) ◽

pp. 241-245 ◽

Cited By ~ 22

Author(s):

Nikita Lakomkin ◽

Mandip Dhamoon ◽

Kirsten Carroll ◽

Inder Paul Singh ◽

Stanley Tuhrim ◽

...

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Review Of The Literature ◽

Qualitative Synthesis ◽

Vessel Occlusion ◽

Number Of Patients ◽

Meta Analyses

BackgroundAccurate assessment of the prevalence of large vessel occlusion (LVO) in patients presenting with acute ischemic stroke (AIS) is critical for optimal resource allocation in neurovascular intervention.ObjectiveTo perform a systematic review of the literature in order to identify the proportion of patients with AIS presenting with LVO on image analysis.MethodsA systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines in order to identify studies reporting LVO rates for patients presenting with AIS. Studies that included patients younger than 18 years, were non-clinical, or did not report LVO rates in the context of a consecutive AIS series were excluded. Characteristics regarding presentation, diagnosis, and LVO classification were recorded for each paper.ResultsSixteen studies, spanning a total of 11 763 patients assessed for stroke, were included in the qualitative synthesis. The majority (10/16) of articles reported LVO rates exceeding 30% in patients presenting with AIS. There was substantial variability in the LVO definitions used, with nine unique classification schemes among the 16 studies. The mean prevalence of LVO was 31.1% across all studies, and 29.3% when weighted by the number of patients included in each study.ConclusionsDespite the wide variability in LVO classification, the majority of studies in the last 10 years report a high prevalence of LVO in patients presenting with AIS. These rates of LVO may have implications for the volume of patients with AIS who may benefit from endovascular therapy.

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What is the impact of head movement on automated CT perfusion mismatch evaluation in acute ischemic stroke?

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017510 ◽

2021 ◽

pp. neurintsurg-2021-017510

Author(s):

Arne Potreck ◽

Fatih Seker ◽

Matthias Anthony Mutke ◽

Charlotte Sabine Weyland ◽

Christian Herweh ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Head Movement ◽

Ct Perfusion ◽

Treatment Decision ◽

Brain Perfusion ◽

Left Middle Cerebral Artery ◽

Ct Scanner ◽

Infarct Core ◽

The Impact

ObjectivesAutomated CT perfusion mismatch assessment is an established treatment decision tool in acute ischemic stroke. However, the reliability of this method in patients with head motion is unclear. We therefore sought to evaluate the influence of head movement on automated CT perfusion mismatch evaluation.MethodsUsing a realistic CT brain-perfusion-phantom, 7 perfusion mismatch scenarios were simulated within the left middle cerebral artery territory. Real CT noise and artificial head movement were added. Thereafter, ischemic core, penumbra volumes and mismatch ratios were evaluated using an automated mismatch analysis software (RAPID, iSchemaView) and compared with ground truth simulated values.ResultsWhile CT scanner noise alone had only a minor impact on mismatch evaluation, a tendency towards smaller infarct core estimates (mean difference of −5.3 (−14 to 3.5) mL for subtle head movement and −7.0 (−14.7 to 0.7) mL for strong head movement), larger penumbral estimates (+9.9 (−25 to 44) mL and +35 (−14 to 85) mL, respectively) and consequently larger mismatch ratios (+0.8 (−1.5 to 3.0) for subtle head movement and +1.9 (−1.3 to 5.1) for strong head movement) were noted in dependence of patient head movement.ConclusionsMotion during CT perfusion acquisition influences automated mismatch evaluation. Potentially treatment-relevant changes in mismatch classifications in dependence of head movement were observed and occurred in favor of mechanical thrombectomy.

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Abstract W P287: Does Comprehensive Stroke Certification Demonstrate a Significant Effect on Volume and Quality of Care?

Stroke ◽

10.1161/str.45.suppl_1.wp287 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Laurie Paletz ◽

Shlee Song ◽

Nili Steiner ◽

Betty Robertson ◽

Nicole Wolber ◽

...

Keyword(s):

Ischemic Stroke ◽

Quality Of Care ◽

Acute Stroke ◽

Acute Ischemic Stroke ◽

Turnaround Time ◽

Joint Commission ◽

Stroke Patients ◽

Number Of Patients ◽

The Impact

Introduction/Background information: At the onset of acute stroke symptoms, speed, capability, safety and skill are essential-lost minutes can be the difference between full recoveries, poor outcome, or even death. The Joint Commission's Certificate of Distinction for Comprehensive Stroke Centers recognizes centers that make exceptional efforts to foster better outcomes for stroke care. While many hospitals have been surveyed, Cedars Sinai was the 5 th hospital in the nation to receive this certification. Researchable question: Does Comprehensive stroke certification (CSC) demonstrate a significant effect on volume and quality of care? Methods: We assembled a cross-functional, multidisciplinary expert team representing all departments and skill sets involved in treating stroke patients. We carefully screened eligible patients with acute ischemic stroke We assessed the number of patients treated at Cedars-Sinai with IV-T-pa t 6 months before and then 6 months after CSC and the quality of their care including medical treatment and door to needle time. Results: In the 6 months prior to Joint Commissions Stroke Certification we treated 20 of 395acute stroke patients with t-PA with an average CT turnaround time of 31±19minutes and an average Door to needle time (DTNT) of 68±32minutes. In the 6 months since Joint Commission Stroke Certification we have increased the number of acute stroke patients treated by almost double. There were 37 out of 489(P=0.02, Chi Square) patients treated with IV t-PA with an average CT turnaround time of 22±7minutes (p=0.08, t-test, compared to pre-CSC) and an average DTNT of 61± 23minutes (not different than pre-CSC). Conclusion: We conclude that Joint Commission Certification for stroke was associated with an increased rate of treatment with IV rt-PA in acute ischemic stroke patients. We were not able to document an effect on quality of care. Further studies of the impact of CSC certification are warranted.

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Abstract 3314: The Role of Bridging with Intravenous Thrombolysis in Endovascular Therapy of Acute Ischemic Stroke.

Stroke ◽

10.1161/str.43.suppl_1.a3314 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Omar Kass-Hout ◽

Tareq Kass-Hout ◽

Maxim Mokin ◽

David Orion ◽

Shadi Jahshan ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Combined Therapy ◽

Large Vessel ◽

P Value ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Nihss Score

Background: Large vessel occlusions with a high clot burden are less likely to improve with the FDA-approved IV strategy. Endovascular therapy within the first 3 h of stroke symptom onset provides an effective alternative treatment in patients with large vessel occlusion. It is not clear if combination of IV thrombolysis and endovascular approach is superior to endovascular treatment alone. Methods: We retrospectively reviewed all cases of acute ischemic stroke with large vessel occlusion treated within the first 3 h stroke onset during the 2005-2010 period. First group received endovascular therapy within the first 3 h of stroke onset. Second group consisted of patients who received IV thrombolysis within the first 3 h followed by endovascular therapy. We compared the following outcomes: revascularization rates, NIHSS score at discharge, mRS at discharge and 3months, symptomatic hemorrhage rates and mortality. Results: Among 104 patients identified, 42 received combined therapy, and 62 received endovascular therapy only. The two groups had similar demographic (age and sex distribution) and vascular risk factors distribution, as well as NIHSS score on admission (14.8±4.7 and 16.0±5.3; p=0.23). We found no difference in TIMI recanalization rates (Thrombolysis in Myocardial Infarction scale score of 2 or 3) following combined or endovascular therapy alone (83.3% and 79.0%; p=0.59). A preferred outcome, defined as a mRS of 2 or less at 90 days also did not differ between the combined therapy group and the endovascular only group (37.5% and 34.5%; p=0.76). There was no difference in mortality rate (22.5% and 31.0%; p=0.36) and the rate of symptomatic intracranial hemorrhage (9.5% and 8.1%; p=0.73). There was a significant difference in mean time from symptom onset to endovascular treatment between the combined group (227±88 min) and endovascular only group (125±40 min; p<0.0001).Patients with good TIMI recanalization rate of 2 or 3 showed a trend of having a better mRS at 90 days in both bridging (16.67% vs. 41.18%, p-value: 0.3813) and endovascular groups (25% vs. 34.78%, p-value: 0.7326).When analyzing the correlation of mRS at 90 days with the site of occlusion, patients in the bridging group showed a trend of a better outcome when the site of occlusion was ICA (33.3% vs 30%) and MCA (66.67% vs. 27.59%) and worse outcome when the site of occlusion was in the posterior circulation (26.32% vs. 50%), however, these results were not statistically significant (p-values: 0.1735& 0.5366). Conclusion: Combining IV thrombolysis and endovascular therapy achieves similar rates of clinical outcomes, revascularization rates, complications and mortality rates, when compared with endovascular treatment alone. The combined therapy, however, significantly delays initiation of endovascular treatment. A randomized prospective trial comparing both treatment strategies in acute ischemic stroke is warranted

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Abstract TP26: Endovascular Therapy and Outcomes in a Large Biracial Cohort of Patients with Acute Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.tp26 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Leticia C Rebello ◽

Aaron Anderson ◽

Diogo C Haussen ◽

Samir R Belagaje ◽

Jonathan A Grossberg ◽

...

Keyword(s):

African American ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Ethnic Disparities ◽

Stroke Outcomes ◽

Good Outcome ◽

Caucasian Patients ◽

Baseline Characteristics ◽

The Impact

Background: The ethnic disparities in stroke outcomes have been well described. Stroke is twice more common and leads to higher mortality rates among blacks as compared to whites. We compared the outcomes of patients undergoing endovascular stroke therapy (ET) in a high-volume center according to their racial profile after age adjustment. Methods: Retrospective analysis of a prospectively collected ET database between September/2010-September/2015. The baseline characteristics of African-American vs. Caucasian patients were compared. Given the impact of age on stroke outcomes additional analyses were performed dichotomizing patients using the median age of the overall cohort. Primary and secondary efficacy outcomes included the rates of good outcome (90-day mRS 0-2) and successful reperfusion (mTICI 2b-3), respectively. Safety outcome was accessed by rates of any parenchymal hematoma (PH-1 and PH-2) and 90-day mortality. Results: 781 patients fit the inclusion criteria and were included in the analysis; 440 were included in the Caucasian group (56% overall cohort) and 341 in the African-American group (44%). Caucasian patients were significantly older (69±13 vs. 60±14 years-old, p<0.01) but the remaining baseline characteristics were otherwise well-balanced. This included similar baseline CT perfusion core volumes (rCBF<30%, 17.6 ± 20.8 vs. 17.9 ± 32.8; p=0.93). There were no differences in the rates successful reperfusion (mTICI 2b-3: 83% vs. 85%, p=0.37), any PH (8% vs. 5%, p=0.26), or final infarct volume (32 IQR 12-89 vs. 25 IQR 9-67; p=0.12) across the two groups. In the overall cohort, there was a lower proportion of 90-day good outcome (39% vs. 49%; p<0.01) and higher 90-day mortality (32% vs. 16%; p<0.01) among Caucasians presumably due to their older age. Subgroup analysis of patients 65 years-old or younger showed similar rates of 90-day good outcomes (59% vs. 53%; p=0.33) and mortality (17% vs. 12%; p=0.22) across Caucasian and African-American patients. Conclusion: Aggressive treatment of acute ischemic stroke with endovascular therapy leads to similar outcomes across African-American and Caucasian patients. Greater availability of ET may diminish the ethnic/racial disparities in stroke outcomes.

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