Abstract 138: Perfusion Imaging of Intracranial Atherosclerotic Disease in SAMMPRIS

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
David S Liebeskind ◽  
Colin P Derdeyn ◽  
Nerses Sanossian ◽  
George A Cotsonis ◽  
Fabien Scalzo ◽  
...  
Keyword(s):  
Perfusion Imaging ◽  
Cerebral Blood Volume ◽  
Mean Transit Time ◽  
Flow Patterns ◽  
Atherosclerotic Disease ◽  
Collateral Flow ◽  
Conventional Angiography ◽  
Presenting Symptoms ◽  
Intracranial Atherosclerotic Disease

Background: Noninvasive perfusion imaging with CT (CTP) or MRI (PWI) provides key physiologic data regarding hemodynamics of intracranial atherosclerotic disease (ICAD). Parameters of delayed perfusion such as Tmax, time to peak (TTP), mean transit time (MTT) and cerebral blood volume (CBV) or flow (CBF) may disclose important mechanisms of stroke in ICAD. We analyzed CTP and PWI acquired in SAMMPRIS to identify the principal perfusion patterns, correlation with conventional angiography and potential links with clinical outcome. Methods: CTP and PWI were identified in the SAMMPRIS imaging archive. Perfusion datasets were processed with Olea Sphere® to yield Tmax, TTP, MTT, CBV and CBF maps graded by 2 expert readers to identify markers of decreased, normal, or increased perfusion in the symptomatic territory. The resultant multiparametric perfusion patterns were correlated with clinical and angiographic variables, using Fisher’s exact test and Kaplan-Meier methods followed by log-rank tests. Results: Perfusion imaging was available in 59 subjects at baseline and 42 at follow-up. Baseline perfusion included Tmax (decreased in 2, normal in 18, increased in 39); TTP (decreased in 2, normal in 18, increased in 39); MTT (decreased in 2, normal in 27, increased in 30); CBV (decreased in 5, normal in 42, increased in 12); CBF (decreased in 7, normal in 48, increased in 4). The baseline Tmax increases in 66% of subjects were associated with the combined (TICI and collaterals) diminished angiographic flow patterns (p=0.016) and with increased 30-day SIT (p=0.015). Baseline CBV changes were associated with stroke as a qualifying event (p=0.007), NIHSS (p=0.039), presenting symptoms of hypoperfusion (p=0.071), severity of stenosis (p=0.015), and angiographic flow patterns (p=0.009). Follow-up CTP or PWI revealed similar patterns to baseline, although delay maps normalized in patients after stenting. Conclusions: Noninvasive perfusion imaging with CT or MRI discloses delayed flow caused by ICAD, often compensated by autoregulatory vasodilation (increased CBV) to maintain CBF in the downstream territory. Perfusion imaging parameters may reflect angiographic collateral flow patterns in ICAD, warranting further investigation as predictors of stroke risk.

Abstract P476: Safety and Efficacy of Balloon Mounted Drug-Eluting Stent in the Treatment of Symptomatic Intracranial Atherosclerotic Disease Multicenter International Experience

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Mahmoud Mohammaden ◽  
Raul G Nogueira ◽  
WONDWOSSEN TEKLE ◽  
farhan siddiq ◽  
Diogo C Haussen ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Endovascular Treatment ◽  
Medical Management ◽  
Randomized Clinical Trials ◽  
Atherosclerotic Disease ◽  
Drug Eluting Stent ◽  
Safety And Efficacy ◽  
Intracranial Atherosclerotic Disease ◽  
Drug Eluting

Introduction: Intracranial atherosclerotic disease (ICAD) is a common cause of refractory stroke. Randomized clinical trials failed to prove the safety and efficacy of the endovascular treatment options of symptomatic ICAD (sICAD). However, there are many concerns regarding inclusion criteria in these trials which made them less effective than standard medical management. Herein, we aim to study the safety and efficacy of drug-eluting balloon mounted stents (DES) in the treatment of sICAD. Methods: A retrospective review of endovascular database from 10 comprehensive stroke centers inside and outside the USA from January 2017 to January 2020 was reviewed. Patients were included if they had symptomatic intracranial stenosis ≥70% in the target vessel, failed best medical management, and underwent intracranial stenting with DES. The primary outcome was the occurrence of ischemic stroke, hemorrhage, or mortality within 72 hours of the procedure. Secondary outcomes included rates of symptomatic and angiographic recurrence within 6 months of the procedure. Results: There was a total of 129 patients, the median age was 65 [58-72] years, 40 (31%) were females. The intracranial stenotic lesions were located in anterior circulation in 74 (57.4%) of cases [24 (18.6%) supraclinoid ICA, 5 (3.9%) cavernous ICA, 17 (13.2%) petrous ICA, 5 (19.4%) MCA-M1, and 3 (2.3%) M2] and in posterior circulation in 55 (42.6%) of cases [36 (27.9) vertebral artery V4 segment, 18 (14%) basilar and 1 (0.7%) PCA]. Recurrent stroke was the qualifying event in 101 (78.3%) while transient ischemic attacks (TIA) were identified in 28 (21.7%) of cases. The median time from the qualifying event to stenting was 6 [2-24] days. Strokes were reported within 72 hours of the procedure; 2 (1.6%) ischemic, 2 (1.6%) hemorrhagic strokes and 2 (1.6%) patients suffered inpatient mortality. The median follow-up time was 6 [3-6.75] months. Among 99 patients who had clinical follow up 2 (2%) had TIA and 6 (6.1%) had strokes. Fifty-one patients had follow-up imaging of whom symptomatic ISR was reported in 8 (15.7%). Conclusion: Our study has shown that in appropriately selected patients with sICAD, endovascular treatment using DES is safe and effective. Prospective randomized clinical trials are warranted.

Symptomatic intracranial atherosclerotic disease: an ultrasound 2-year follow-up pilot study

2018 ◽  
Vol 39 (11) ◽  
pp. 1955-1959 ◽  
Author(s):  
Pietro Caliandro ◽  
Giuseppe Reale ◽  
Andrew M. Demchuk ◽  
Valeria Caso ◽  
Anita Arsovska ◽  
...  
Keyword(s):  
Pilot Study ◽  
Atherosclerotic Disease ◽  
Intracranial Atherosclerotic Disease

Abstract MP48: Intracranial Dolichoectasia in Patients With Symptomatic Intracranial Atherosclerotic Disease: The Myriad Study

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Victor J Del Brutto ◽  
Azhar Nizam ◽  
george cotsonis ◽  
Iszet Campo-Bustillo ◽  
David S Liebeskind ◽  
...  
Keyword(s):  
Brain Mri ◽  
Early Recurrence ◽  
Atherosclerotic Disease ◽  
Common Finding ◽  
Stroke Recurrence ◽  
Entire Cohort ◽  
Intracranial Atherosclerotic Disease ◽  
Study Population ◽  
Ischemic Events

Background: It is unknown whether intracranial atherosclerotic disease (IAD), in addition to vessel narrowing, also contributes to the abnormal dilation and increased tortuosity of intracranial vessels, a condition known as intracranial dolichoectasia (IDE). We aim to determine the degree to which these two arteriopathies coexist and whether IDE correlates with subsequent ischemic events in patients with recently symptomatic moderate-to-severe IAD. Methods: The study included 99 patients (mean age 6311 years; 57% men) enrolled in the Mechanisms of Early Recurrence in Intracranial Atherosclerotic Disease (MyRIAD) study. Intracranial vessels diameter, length, and tortuosity were determined by semiautomatic vessel segmentation and were considered abnormal if ≥2 standard deviations from the study population mean. Either ectasia (increased diameter) or dolichosis (increased tortuosity) defined IDE. We assessed the correlation of IDE in the symptomatic vessel with the composite outcome of either new infarcts in the territory of the affected vessel on brain MRI performed at 6-8 weeks from the index event or stroke recurrence during 12-month follow up. Results: IDE prevalence was 34% (isolated ectasia 8%, isolated dolichosis 18%, and both ectasia and dolichosis 8%) and 14% of symptomatic vessels. Patients with and without IDE had similar demographics and vascular risk factors prevalence (Table). I Twenty-two out of 85 (26%) patients with brain MRI at 6-8 weeks had new infarct(s) in the territory and 9% of the entire cohort had stroke recurrence during follow-up. Coexistence of IAD and IDE in the target vessel was not associated to subsequent ischemic events (21.4% versus 29.4%; P=0.54). Conclusion: IDE is a common finding in patients with moderate-to-severe IAD. Superimposed IDE did not increase the already heightened risk of subsequent ischemic events in patients with symptomatic IAD. ClinicalTrials.gov Identifier: NCT02121028

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 T P37: Cerebral Blood Volume Does Not Differentiate Regions With Persistent Cerebral Hypoperfusion That Infarct From Those That Survive: A DEFUSE 2 Substudy

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Sharan K Mann ◽  
Soren Christensen ◽  
Michael Mlynash ◽  
Stephanie Kemp ◽  
Maarten G Lansberg ◽  
...  
Keyword(s):  
Blood Flow ◽  
Blood Volume ◽  
Cerebral Blood Volume ◽  
Mean Transit Time ◽  
T Test ◽  
Cerebral Hypoperfusion ◽  
Lesion Volume ◽  
Mri Scan ◽  
Paired T Test

Background: The optimal Tmax threshold for predicting critically hypoperfused tissue is a delay of >6 seconds. However, persistent Tmax >6s lesions do not invariably progress to infarction. Differences in cerebral blood volume (CBV) may explain why some regions of persistent cerebral hypoperfusion (PCHP) infarct whereas others survive. We hypothesized that CBV is higher in areas of PCHP that survive versus those that infarct. Methods: We included patients that had: 1) a Tmax >6s lesion on baseline and early follow-up MRI perfusion scans, and 2) a FLAIR lesion on the day 5 MRI scan. Regions of PCHP had to meet two criteria: 1) Tmax >6s positive on both baseline and co-registered early follow-up MRI perfusion scans, and 2) DWI negative on the baseline MRI scan. PCHP regions were classified as PCHP-infarct if there was a corresponding lesion on the co-registered 5 day FLAIR and as PCHP-survival if there was no corresponding lesion. Patients with no region of either PCHP-infarct or PCHP-survival were excluded. The study had two parts. In part 1, the paired t-test was used to compare lesion volume, CBV, cerebral blood flow (CBF), mean transit time (MTT), and Tmax between PCHP-infarct and PCHP-survival regions within each patient. In part 2, the 2-sample t-test was used to compare mean volume, CBV, CBF, MTT, and Tmax in PCHP-infarct and PCHP-survival regions for all patients together as a group. Results: 61 patients were included in the analysis. Mean total PCHP volume was 26cc (16cc infarct, 10cc survival) and median total PCHP volume was 15cc (9cc infarct, 6cc survival). For part 1, CBV was not different in PCHP-infarct versus PCHP-survival (P=0.16). CBF was higher (P=0.05) in regions of PCHP-survival, and MTT and Tmax were less prolonged (P=0.03 and P < 0.01). For part 2, mean CBV and MTT did not differ between PCHP-infarct and PCHP-survival (P=0.23 and P=0.40). Mean CBF trended higher (P=0.07) and mean Tmax delays were milder (P= 0.04) in PCHP-survival. Conclusion: CBV does not differ between regions of PCHP-infarct versus PCHP-survival and does not explain why some areas of persistent, severe hypoperfusion survive. Tmax was less severely delayed and CBF values were higher in regions of PCHP-survival, which warrant further study.

Abstract 68: Impaired Perfusion in Intracranial Atherosclerotic Disease Predicts Cognitive Outcomes

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
David S Liebeskind ◽  
Jose G Romano ◽  
George A Cotsonis ◽  
Shadi Yaghi ◽  
Tristan Honda ◽  
...  
Keyword(s):  
Collateral Circulation ◽  
Recurrent Stroke ◽  
Cognitive Outcomes ◽  
Cognitive Testing ◽  
Atherosclerotic Disease ◽  
Collateral Flow ◽  
Cognitive Changes ◽  
Intracranial Atherosclerotic Disease ◽  
Antegrade Flow

Background: Poor collateral circulation and hypoperfusion may lead to recurrent stroke in intracranial atherosclerotic disease (ICAD). The role of perfusion in silent strokes and potentially insidious cognitive impairment in ICAD is unknown. We used evidence of impaired perfusion at angiography in SAMMPRIS to predict subsequent cognitive changes. Methods: Angiography at enrollment in the SAMMPRIS trial was independently evaluated, blind to clinical data and cognitive testing. Antegrade flow in the symptomatic arterial territory and corresponding collateral flow were scored. Impaired perfusion was defined by poor antegrade and poor collateral flow. Serial testing with the Montreal Cognitive Assessment (MoCA) was done in subjects without aphasia or neglect at baseline, 4 mo, 12 mo and closeout, or until subjects had a clinical stroke endpoint. Results: 207 subjects (median age 61, range 33-81 years; 37% women) had baseline MoCA scores with angiography data on territorial perfusion. Baseline MoCA scores (mean 24.2±4.1) were similar between categories of antegrade flow and collateral circulation. Impaired perfusion was noted in 33/207 (16%). Serial MoCA revealed that changes in cognition over time were different at 4 mo, 12 mo and closeout based on the presence of impaired perfusion at baseline (p<0.001). After more modest (mean MoCA change = 0.5 increase from baseline, p=0.80) early improved cognitive function at 4 mo, those with impaired perfusion had cognitive decline at 12 mo (mean MoCA change, p<0.01) unlike the continued improvement in other subjects. Cognitive changes in those with impaired perfusion were associated with a higher frequency of subsequent stroke in the territory. Conclusions: Impaired perfusion in the symptomatic arterial territory of ICAD predicts cognitive outcomes that may precede recurrent ischemia. Future studies may define the role of noninvasive perfusion imaging in ICAD to predict cognitive trajectories and recurrent stroke.

scholarly journals Predictive Value of the Velocity of Collateral Filling in Patients with Acute Ischemic Stroke

2014 ◽  
Vol 35 (2) ◽  
pp. 206-212 ◽  
Author(s):  
Sebastian E Beyer ◽  
Louisa von Baumgarten ◽  
Kolja M Thierfelder ◽  
Marietta Rottenkolber ◽  
Hendrik Janssen ◽  
...  
Keyword(s):  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Mean Transit Time ◽  
Intravenous Thrombolysis ◽  
Lesion Size ◽  
Small Lesion ◽  
Time Resolved ◽  
Time To Peak ◽  
Magnetic Resonance Imaging Mri

The velocity of collateral filling can be assessed in dynamic time-resolved computed tomography (CT) angiographies and may predict initial CT perfusion (CTP) and follow-up lesion size. We included all patients with an M1± internal carotid artery (ICA) occlusion and follow-up imaging from an existing cohort of 1791 consecutive patients who underwent multimodal CT for suspected stroke. The velocity of collateral filling was quantified using the delay of time-to-peak (TTP) enhancement of the M2 segment distal to the occlusion. Cerebral blood volume (CBV) and mean transit time (MTT)-CBV mismatch were assessed in initial CTP. Follow-up lesion size was assessed by magnetic resonance imaging (MRI) or non-enhanced CT (NECT). Multivariate analyses were performed to adjust for extent of collateralization and type of treatment. Our study comprised 116 patients. Multivariate analysis showed a short collateral blood flow delay to be an independent predictor of a small CBV lesion ( P<0.001) and a large relative mismatch ( P<0.001) on initial CTP, of a small follow-up lesion ( P<0.001), and of a small difference between initial CBV and follow-up lesion size ( P=0.024). Other independent predictors of a small lesion on follow-up were a high morphologic collateral grade ( P=0.001), lack of an additional ICA occlusion ( P=0.009), and intravenous thrombolysis ( P=0.022). Fast filling of collaterals predicts initial CTP and follow-up lesion size and is independent of extent of collateralization.

Drug-coated balloons for the treatment of symptomatic intracranial atherosclerosis: initial experience and follow-up outcome

2018 ◽  
Vol 11 (6) ◽  
pp. 569-573 ◽  
Author(s):  
Ju Han ◽  
Jun Zhang ◽  
Xiao Zhang ◽  
Jinping Zhang ◽  
Yun Song ◽  
...  
Keyword(s):  
De Novo ◽  
Perioperative Complications ◽  
Vascular Imaging ◽  
Atherosclerotic Disease ◽  
Total Occlusion ◽  
Stent Restenosis ◽  
Intracranial Atherosclerotic Disease ◽  
Artery Disease ◽  
Angioplasty And Stenting

BackgroundThe optimal treatment for patients with symptomatic severe intracranial atherosclerotic disease is not well established. Angioplasty and stenting have been attempted, with controversial results, mainly attributed to perioperative complications and a high incidence of restenosis or in-stent restenosis. Drug-coated balloons (DCBs) have shown encouraging results for coronary and peripheral artery disease, without convincing data for intracranial vasculature.ObjectivesTo assess the feasibility, clinical and angiographic outcomes of DCBs for patients with intracranial de novo atherosclerotic disease.MethodsBetween September 2016 and September 2017, details of 30 patients with 31 arteries treated with DCBs for symptomatic severe intracranial atherosclerotic disease (≥70% stenosis or chronic total occlusion) were retrospectively collected in our centre. All lesions were predilated with conventional balloons. Periprocedural complications and clinical and vascular imaging follow-up outcomes were analysed.ResultsAll arteries were successfully dilated with DCBs and 29 (93.5%) arteries achieved good antegrade perfusion, with remedial stenting for two arteries. Two patients presented with new ischemic stroke after the procedure. Over a mean follow-up of 9.8±2.6 months, no patient had recurrent ischemic symptoms. Repeat vascular imaging was performed at 7.0±1.1 months, with cerebral angiography in 24 patients (25 arteries) and MR angiography in six patients (six arteries). Only one (3.2%) artery presented with angiographic asymptomatic restenosis.ConclusionsThis study suggests that DCB dilatation may be a safe and effective alternative for intracranial de novo atherosclerotic disease.

scholarly journals Transit time homogenization in ischemic stroke – A novel biomarker of penumbral microvascular failure?

2017 ◽  
Vol 38 (11) ◽  
pp. 2006-2020 ◽  
Author(s):  
Thorbjørn S Engedal ◽  
Niels Hjort ◽  
Kristina D Hougaard ◽  
Claus Z Simonsen ◽  
Grethe Andersen ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Transit Time ◽  
Animal Studies ◽  
Cerebral Blood Volume ◽  
Mean Transit Time ◽  
Data Interpretation ◽  
Transit Times ◽  
Human Stroke ◽  
Historic Cohort

Cerebral ischemia causes widespread capillary no-flow in animal studies. The extent of microvascular impairment in human stroke, however, is unclear. We examined how acute intra-voxel transit time characteristics and subsequent recanalization affect tissue outcome on follow-up MRI in a historic cohort of 126 acute ischemic stroke patients. Based on perfusion-weighted MRI data, we characterized voxel-wise transit times in terms of their mean transit time (MTT), standard deviation (capillary transit time heterogeneity – CTH), and the CTH:MTT ratio (relative transit time heterogeneity), which is expected to remain constant during changes in perfusion pressure in a microvasculature consisting of passive, compliant vessels. To aid data interpretation, we also developed a computational model that relates graded microvascular failure to changes in these parameters. In perfusion–diffusion mismatch tissue, prolonged mean transit time (>5 seconds) and very low cerebral blood flow (≤6 mL/100 mL/min) was associated with high risk of infarction, largely independent of recanalization status. In the remaining mismatch region, low relative transit time heterogeneity predicted subsequent infarction if recanalization was not achieved. Our model suggested that transit time homogenization represents capillary no-flow. Consistent with this notion, low relative transit time heterogeneity values were associated with lower cerebral blood volume. We speculate that low RTH may represent a novel biomarker of penumbral microvascular failure.

scholarly journals Perfusion Changes in Acute Stroke Treated with Theophylline as an Add-on to Thrombolysis

2021 ◽  
Author(s):  
Boris Modrau ◽  
Anthony Winder ◽  
Niels Hjort ◽  
Martin Nygård Johansen ◽  
Grethe Andersen ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Cerebral Blood Volume ◽  
Neuroprotective Effect ◽  
Mean Transit Time ◽  
Control Group ◽  
Infarct Core ◽  
Treatment Groups ◽  
Stroke Models ◽  
Magnetic Resonance Imaging Mri

Abstract Purpose Theophylline has been suggested to have a neuroprotective effect in ischemic stroke; however, results from animal stroke models and clinical trials in humans are controversial. The aim of this study was to assess the effect of theophylline on the cerebral perfusion with multiparametric magnetic resonance imaging (MRI). Methods The relative cerebral blood flow (rCBF), relative cerebral blood volume (rCBV), and relative mean transit time (rMTT) in the infarct core, penumbra, and unaffected tissue were measured using multi-parametric MRI at baseline and 3‑h follow-up in patients treated with theophylline or placebo as an add-on to thrombolytic therapy. Results No significant differences in mean rCBF, rCBV, and rMTT was found in the penumbra and unaffected tissue between the theophylline group and the control group between baseline and 3‑h follow-up. In the infarct core, mean rCBV increased on average by 0.05 in the theophylline group and decreased by 0.14 in the control group (p < 0.04). Mean rCBF and mean rMTT in the infarct core were similar between the two treatment groups. Conclusion The results indicate that theophylline does not change the perfusion in potentially salvageable penumbral tissue but only affects the rCBV in the infarct core. In contrast to the penumbra, the infarct core is unlikely to be salvageable, which might explain why theophylline failed in clinical trials.

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