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

Stroke ◽  
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.

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

Stroke ◽  
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

Abstract WP22: Endovascular Treatment for Distal Middle cerebral Artery Occlusions in Patients with Acute Ischemic Stroke From Interventional Management of Stroke Trial (IMS III)

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Mohammad R Afzal ◽  
Mohtashim A Qureshi ◽  
Ihtesham A Qureshi ◽  
Paisith Piriyawat ◽  
Alberto Maud ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Natural History ◽  
Endovascular Treatment ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Infarct Volume ◽  
Favorable Outcome ◽  
P Value ◽  
History Of ◽  
Stroke Trial

Background: Currently, endovascular treatment is advocated for middle cerebral artery (MCA) occlusions, however not much is known about the natural history of an M1 compared to an M2 occlusion. Objective: To compare the clinical outcome in endovascularly treated patients with proximal vessel occlusion (M1) versus a more distal occlusion (M2) among patients with ischemic stokes in a negative trial. Methods: Data from Interventional Management of Stroke trial (IMS-III) for patients with acute ischemic stroke with distal MCA (mainly M2 and beyond) occlusions diagnosed by either computed tomographic angiography (CTA) or catheter angiography were analyzed. NIHSS at admission, baseline characteristics, infarct volume at baseline and outcome at 90 days (mRS score) were compared between the two groups. Favorable outcome was defined by discharge modified Rankin scale (mRS) score of 0-2, at 3 months. Multivariate logistical regression was performed to compare the outcomes after adjusting for potential confounders. Results: Of the 434 from the endovascular therapy group, 215 (49.5%) and 98 (22.5%) patients had M1 and M2 occlusion respectively. Patients with M1 occlusion had higher mean NIHSS at admission (18.76± 4.94 versus 17.37± 5.72, P-value = 0.029) and higher infarct volume (105.92 ± 113.23 versus 49.67 ± 63.42, P-value = 0.000) . Rate of favorable outcome defined by mRS at discharge was lower among patients with M1 (31.53%vs.46.67%p-value = 0.0128) . After adjusting for age, sex, total NIHSS score at admission, hepato-biliary disorders, anticoagulants, antiplatelet, NSAIDS, patients with M1 occlusion had higher rates of poor outcomes; odds ratio (OR) 1.819 (confidence interval [CI] 1.032- 3.205, P=0.03860). Conclusions: In patients enrolled in IMS-III trial, an M1 occlusion demonstrated a larger tissue infarct size and a lower rate of favorable outcome than an M2 occlusion, given the negative results of the trial, these findings reflect the natural history of these two occlusion sites.

Abstract P580: Prevalence and Natural History of Large Vessel Occlusion in Childhood Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Wilmot Bonnet ◽  
Michael M Dowling ◽  
Patricia Plumb
Keyword(s):  
Ischemic Stroke ◽  
Natural History ◽  
Acute Ischemic Stroke ◽  
Chart Review ◽  
Pediatric Population ◽  
Adult Population ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
History Of

Introduction: Many studies have reported endovascular revascularization therapy (ERT) in children with Childhood Acute Ischemic Stroke (CAIS). With the recent expansion of thrombectomy windows via DAWN/DEFUSE3, more pediatric stroke patients are likely to be potential candidates for intervention. The prevalence of Large Vessel Occlusion (LVO) in the adult population is 25-33% however the prevalence and natural history of LVO in the pediatric population have not yet been described. Methods: This is an IRB approved single center observational study by retrospective chart review of all CAIS who presented acutely to our center from 2004 to 2019. Components of Chart review: Vessel involvement, Mortality/dependency, PSOM and MRS, Etiology, Intervention/Time window of presentation/eligibility for DAWN/DEFUSE, treatment (thrombolysis, ERT), and outcome. Results: 48/218 (22%) of patients with CAIS had an acute presentation consistent with LVO (95% CI 16.7-28.1%). Of the patients with LVO, 23 (46%) were due to large vessel arteriopathy, 15(30%) were cardioembolic, 4 had a hypercoagulable state and 7 were cryptogenic. Ages ranged from day of life 1 to 18 years. 6 (12%) patients died within 2 years of LVO (3 of stroke, 3 from other causes). 5 of the 218 patients reviewed received thrombolysis, with 4/48 LVO patients received thrombolytics. 5/49 LVO patients underwent ERT (4 with at least TICI 2A reperfusion). Average age of LVO patients 14.2 years. PSOM/ comparative outcome data collection is ongoing. Conclusion: Prevalence of LVO has not yet been described in the pediatric population. At our center, 22.4% of CAIS patients had imaging consistent with large vessel occlusion at presentation. This rate is close to that of the adult population (25-33%). Many children have tolerated ERT with good outcomes. Time windows may be less applicable in children given presence of better collaterals and good cardiovascular function. More data is needed regarding the use of advanced imaging modalities for patient stratification in acute neurovascular intervention. Different inclusion criteria may be necessary given improved outcomes among children without intervention.

Abstract 127: Predictors of Good Functional Outcomes in an Acute Ischemic Stroke Cohort with a Large Infarct Core Treated with Mechanical Thrombectomy: Signals to Treat?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jeffrey Wagner ◽  
Donald Frei ◽  
Raul Nogueira ◽  
Adnan Siddiqui ◽  
Osama O Zaidat ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcomes ◽  
Mechanical Thrombectomy ◽  
Infarct Volume ◽  
Target Vessel ◽  
Infarct Core ◽  
Nihss Score ◽  
Good Outcome ◽  
Large Infarct

Purpose: Mechanical thrombectomy has been demonstrated to provide benefits in the treatment of acute ischemic stroke (AIS). But whether to treat AIS patients with a large infarct core remains controversial. Although it is a common practice that patients with large infarct core are not offered endovascular treatment, previous data have consistently shown a proportion of these patients may benefit from IA intervention. The purpose of this study is to identify predictors of good outcomes in an AIS cohort with a large infarct volume previously treated with mechanical thrombectomy. Hypothesis: We hypothesize that among AIS patients with a large infarct volume, younger patients (≤66 years) who present with lower NIHSS scores will show good functional outcomes (mRS 0-2) at 90 days if treated with mechanical thrombectomy. Methods: Univariable and multivariable analyses were preformed to identify factors that predict good functional outcomes in AIS patients with ASPECTS 0-5 who were treated with the Penumbra System. Five previous prospective, multicenter trials (PIVOTAL, PICS, RetroSTART, START, SEPARATOR 3D) were included in this study. Patients who presented with symptoms of AIS were analyzed for association between presenting demographics and modified Rankin scale (mRS) score at 90 days in univariate and multivariate analyses. Results: Data for 614 patients with a median age of 69 years and an NIHSS score of 18 met study criteria. Of these, the 90-day mRS 0-2 rate and mortality were, respectively, 40.23% and 25.41%. Among those with ASPECTS 0-5 (N=93), 17.20% had good functional outcome. An age of ≤66 years was significantly associated with good outcome (p<0.0001) among those with ASPECTS 0-5. Within this age group who had ASPECTS 0-5, a baseline NIHSS score of ≤ 20 (p= 0.0088) with a target vessel location at the MCA (p=0.0210) were also strong predictors of good outcome if treated by mechanical thrombectomy. Conclusion: These data demonstrate that age ≤66 years, baseline NIHSS score of ≤ 20 with a target vessel location in the MCA are important predictors of good outcomes in an AIS cohort with a large infarct core who are eligible for mechanical thrombectomy.

Early neurologic decline in acute ischemic stroke patients receiving thrombolysis with large vessel occlusion and mild deficits

2020 ◽  
Vol 12 (11) ◽  
pp. 1085-1087 ◽  
Author(s):  
Vivien H Lee ◽  
Gaurav Thakur ◽  
Shahid M Nimjee ◽  
Patrick P Youssef ◽  
Sushil Lakhani ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Intravenous Tissue Plasminogen Activator ◽  
History Of ◽  
The Mean ◽  
Mean Time

BackgroundWe sought to determine the rate of early neurologic decline (END) in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) who presented with mild deficits and received intravenous tissue plasminogen activator (IVtPA).MethodsAmong 1022 patients with AIS who received IVtPA from 2014 to 2019, we identified 313 (30.6%) with LVO, of which 94 (30%) presented with National Institute of Health Stroke Scale (NIHSS) score ≤7. Thirteen patients were excluded, leaving 81 for analysis. END was defined as NIHSS worsening of ≥4 points within 24 hours.ResultsAmong 81 patients with LVO and low NIHSS score, the mean age was 65.8 years (range 25–93) and 41% were female. The mean time to IVtPA from last known well was 2.5 hours (range 0.8–7). LVO sites were as follows: 5 (6%) carotid, 23 (28%) M1, and 53 (65%) M2 occlusions. Among the 81 patients, 28 (34.6%) had END, and these patients were older (70.8 vs 63.2 years, p=0.036). The mean change in NIHSS score at 24 hours in those with END was 10.4 (range 4–22). Patients with END were less likely to be discharged home (25% vs 66%, p=0.004).ConclusionsAmong patients with LVO AIS who received IVtPA, 30% presented with initial mild deficits. END occurred in one-third of LVO patients with initial mild deficits despite receiving IVtPA. Clinicians should be aware that the natural history of LVO with initial mild deficits is not benign and these patients are eligible for rescue thrombectomy in the 24-hour window if they deteriorate.

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

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Osama O Zaidat ◽  
Albert Yoo ◽  
Vallabh Janardhan ◽  
Don Frei ◽  
Lynne Ammar ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Status ◽  
Endovascular Therapy ◽  
Treatment Effect ◽  
Large Vessel ◽  
Infarct Core ◽  
Number Of Patients ◽  
The Impact

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.

Abstract 2825: History of Cancer Predicts Mortality After Acute Endovascular Treatment for Ischemic Stroke

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Karl Meisel ◽  
Mahesh Jayaraman ◽  
Jonathan Grossberg ◽  
Anthony Kim
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Hospice Care ◽  
Exploratory Analysis ◽  
Endovascular Intervention ◽  
Consecutive Series ◽  
History Of ◽  
History Of Cancer

Introduction: Endovascular treatment is an emerging therapy for acute ischemic stroke. There is no clear consensus about how best to select patients that may benefit from intervention. We conducted an exploratory analysis of clinical risk factors to predict mortality after endovascular intervention in order to better understand how to improve outcomes for patients with acute ischemic stroke. Methods: We identified consecutive series of patients treated with endovascular therapy for acute ischemic stroke at two academic hospitals between 2005 to 2010. Key clinical data elements and clinical outcomes at the time of discharge were abstracted from medical records. We evaluated univariate and multivariable associations using logistic regression and compared mean NIH Stroke Scale between those with and without a history of cancer using the t-test. Results: We identified 88 patients who received endovascular intervention with intra-arterial tissue plasminogen activator (t-PA) and/or mechanical thrombectomy. The mean age of the cohort was 68.2 (SD 16.6) and 44 (55%) were female. A total of 23 (26.1%) patients died during the index hospitalization or were discharged to hospice care. A history of cancer was documented in 20 (22.7%) patients. A history of cancer was associated with a 3.2-fold (95% CI 1.1-9.1) higher odds of mortality. This association persisted after adjusting for age greater than 80 years and hypertension (OR of 4.0, 95% CI 1.3-12). The average NIH Stroke Scale was 15.6 in those with cancer compared to 14.6 without (p=0.53). A history of cancer was not associated with parenchymal hemorrhagic transformation (OR 1.2, 95% CI 0.3-4.9), IV tPA (OR 0.5, 95% CI 0.1-2.3), a TIMI score of 2b or 3 (OR 0.5, 95% CI 0.2-1.3), or an internal carotid artery occlusion (OR 1.7, 95% CI 0.5-5.1). Conclusions: In an exploratory analysis of consecutive patients with acute ischemic stroke treated with endovascular therapy, a history of cancer was strongly associated with significantly increased odds of mortality. One possible explanation could be that patients with cancer may have earlier withdrawal of care but the reasons for this observed association are unclear. Further investigation is necessary to verify and explain the reasons for this observation in order to improve outcomes for acute ischemic stroke patients.

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