Abstract 40: The Disappearing Core: Time to Re-think Irreversible Injury in This Era of Endovascular Therapy

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Amie W Hsia ◽  
Marie Luby ◽  
Rocco Armonda ◽  
Ai-hsi Liu ◽  
Richard T Benson ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Endovascular Therapy ◽  
Good Clinical Outcome ◽  
New Era ◽  
Neurological Improvement ◽  
Acute Lesion ◽  
Ischemic Core ◽  
Irreversible Injury ◽  
Iv Tpa

Background and Purpose: Early and complete recanalization achieved in this new era of endovascular therapy (ET) can result in nearly imperceptible lesions on post-treatment MRI. In this context we have observed a pattern of lesion evolution on MRI that is atypical from that seen following IV tPA alone, including striking reversal of the ischemic core. We sought to determine the frequency of acute lesion reversal following ET, and its association with sustained reversal and clinical outcome. Methods: Patients were included in this study if: 1) ET for anterior territory ischemic stroke from Jan 2015 to July 2016, 2) baseline pre-ET and 24h MRI, and 3) consent for research. Two raters evaluated ADC maps for early “reversal” (defined visually as >50%) by comparing 24h to baseline. FLAIR MRI at 30d were later assessed for reversal from baseline, blinded to 24h scan. Early neurological improvement (ENI) was defined as decrease in NIHSS≥8 at 24h. Good clinical outcome defined as mRS≤2. Results: Twenty-two patients were included: median age 68.5 years, 73% women, median baseline NIHSS 19. Median time from last known well to recanalization 254 min. TICI 2b/3 in 91%. ADC reversal in 12 of 22 (55%) at 24h. Reversal at 30d was associated with 24hr (p=0.002) with two having no visually appreciable infarct at 30d. Baseline NIHSS did not differ for early reversal versus without (18.5 vs. 19.5), however NIHSS differed at discharge (1.5 vs. 8.5, p=0.003); early reversal is significantly associated with ENI (83% vs. 30%, p=0.027), but not with good clinical outcome at 30-90d (50% vs. 30%, p=0.415). Conclusions: In this new era of consistently effective ET, salvageable tissue includes not just penumbra but ischemic core, previously considered irreversibly injured. Despite lesion reversal and ENI, for some patients, independent outcome is not achieved, a finding that reinforces the need for adjunctive treatments to build upon the success of ET. Figure: Example of a patient with early ADC reversal.

scholarly journals Acute Ischemic Stroke in Late Pregnancy Treated with Intravenous Thrombolysis and Endovascular Therapy

2019 ◽  
Vol 11 (1) ◽  
pp. 41-46 ◽  
Author(s):  
Eva Szuchy Kristiansen ◽  
Hannah Holm Vestergaard ◽  
Boris Modrau ◽  
Lorenz Martin Oppel
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Intravenous Thrombolysis ◽  
Late Pregnancy ◽  
Exclusion Criterion ◽  
Good Clinical Outcome ◽  
Systemic Thrombolysis ◽  
In Pregnancy

Pregnancy has usually been an exclusion criterion in clinical trials with thrombolysis and endovascular therapy in acute ischemic stroke. For that reason, these therapies are not recommended causing lack of evidence and vice versa. In this case report, we describe a pregnant woman in week 33 + 3 presenting with acute ischemic stroke, which was successfully treated with systemic thrombolysis and endovascular therapy, resulting in a good clinical outcome for both mother and child. The altered fibrinolytic system and the risk factors related to pregnancy constitute a challenge for clinicians when choosing the most suitable treatment modality for treating acute ischemic stroke in pregnancy. It is still uncertain whether thrombolysis in combination with endovascular therapy or endovascular therapy alone is the most appropriate treatment option. However, there is slowly growing evidence that thrombolysis and thrombectomy in pregnancy are feasible and safe with a good clinical outcome for both the mother and the child.

Abstract W P54: Cardioembolic Strokes Have an Improved Clinical Outcome Following Intravenous Thrombolysis in Comparison With Strokes Caused by Large Vessel Disease

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Marie Louise Schmitz ◽  
Claus Z. Simonsen ◽  
Irene K. Mikkelsen ◽  
Marie Louise Svendsen ◽  
Heidi Larsson ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Confidence Interval ◽  
Large Vessel ◽  
Stroke Subtype ◽  
Neurological Improvement ◽  
Vessel Disease ◽  
Ischemic Stroke Subtype ◽  
Large Vessel Disease ◽  
Iv Tpa

Introduction: Ischemic stroke prognosis given standard therapy differs according to the underlying pathophysiology. In contrast, the impact of ischemic stroke subtype on clinical outcome in patients treated with intravenous tissue-type plasminogen activator (IV-tPA) is less clear. Objectives: We examined the association between ischemic stroke subtype and clinical outcome in magnetic resonance imaging (MRI)-selected patients treated with IV-tPA. Methods: We included consecutive MRI-evaluated patients treated with IV-tPA in a Danish stroke center between 2004 and 2010. Patients with DWI lesions >1/3 of the middle cerebral artery territory were excluded from treatment. The TOAST criteria were used to classify patients into a stroke subtype based on the results of the complete diagnostic work-up available at three months. A favorable 90-day outcome was defined as a modified Rankin Scale score of 0 to 1. Early neurological improvement was defined as complete remission of the neurologic deficit or an improvement of ≥4 on the NIHSS at 24 hours. Multivariable logistic regression analyses were used to compare outcomes among stroke subtypes adjusted for clinical and imaging characteristics. Results: A total of 557 patients were analyzed: 202 (36%) had large vessel disease, 153 (27%) had cardioembolic stroke, 109 (20%) had small vessel disease and 93 (17%) were of other or undetermined etiology. A favorable outcome was achieved by 361 (64.8%) patients. Patients with cardioembolic strokes were more likely to achieve a favorable outcome as opposed to large vessel disease patients (adjusted OR, 2.9 (95% confidence interval, 1.1-7.4)). Similarly, the probability of an early neurological improvement was increased in cardioembolic stroke patients in comparison with large vessel disease patients (adjusted OR, 3.5 (95% confidence interval, 1.6-7.6)). Conclusions: The ischemic stroke subtype influenced early as well as late clinical outcome after treatment with IV-tPA in MRI-selected patients. Our findings argue for a potentially more successful IV-tPA-induced recanalization in strokes of cardioembolic origin in comparison with large vessel disease strokes.

CTA collateral score predicts infarct volume and clinical outcome after endovascular therapy for acute ischemic stroke: a retrospective chart review

2015 ◽  
Vol 8 (6) ◽  
pp. 559-562 ◽  
Author(s):  
Lucas Elijovich ◽  
Nitin Goyal ◽  
Shraddha Mainali ◽  
Dan Hoit ◽  
Adam S Arthur ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Chart Review ◽  
Infarct Volume ◽  
Retrospective Chart Review ◽  
Favorable Outcome ◽  
Good Clinical Outcome

BackgroundAcute ischemic stroke (AIS) due to emergent large-vessel occlusion (ELVO) has a poor prognosis.ObjectiveTo examine the hypothesis that a better collateral score on pretreatment CT angiography (CTA) would correlate with a smaller final infarct volume and a more favorable clinical outcome after endovascular therapy (EVT).MethodsA retrospective chart review of the University of Tennessee AIS database from February 2011 to February 2013 was conducted. All patients with CTA-proven LVO treated with EVT were included. Recanalization after EVT was defined by Thrombolysis in Cerebral Infarction (TICI) score ≥2. Favorable outcome was assessed as a modified Rankin Score ≤3.ResultsFifty patients with ELVO were studied. The mean National Institutes of Health Stroke Scale score was 17 (2–27) and 38 of the patients (76%) received intravenous tissue plasminogen activator. The recanalization rate for EVT was 86.6%. Good clinical outcome was achieved in 32% of patients. Univariate predictors of good outcome included good collateral scores (CS) on presenting CTA (p=0.043) and successful recanalization (p=0.02). Multivariate analysis confirmed both good CS (p=0.024) and successful recanalization (p=0.009) as predictors of favorable outcome. Applying results of the multivariate analysis to our cohort we were able to determine the likelihood of good clinical outcome as well as predictors of smaller final infarct volume after successful recanalization.ConclusionsGood CS predict smaller infarct volumes and better clinical outcome in patients recanalized with EVT. These data support the use of this technique in selecting patients for EVT. Poor CS should be considered as an exclusion criterion for EVT as patients with poor CS have poor clinical outcomes despite recanalization.

scholarly journals Study Criteria Applied to Real Life—A Multicenter Analysis of Stroke Patients Undergoing Endovascular Treatment in Clinical Practice

2021 ◽  
Author(s):  
Hannes Leischner ◽  
Caspar Brekenfeld ◽  
Lukas Meyer ◽  
Gabriel Broocks ◽  
Tobias Faizy ◽  
...  
Keyword(s):  
Clinical Trials ◽  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Endovascular Treatment ◽  
Endovascular Therapy ◽  
Daily Practice ◽  
Inclusion Criteria ◽  
Good Clinical Outcome ◽  
Anterior Circulation ◽  
Mr Clean

Background Randomized controlled clinical trials (RCT) have demonstrated the efficacy of endovascular treatment in anterior circulation large vessel occlusions. However, outcome of patients treated in daily practice differs from the results of the clinical trials. We hypothesize that this is attributable to the study criteria and that application of the criteria on patients undergoing endovascular therapy in daily routine would improve their outcome. Methods and Results Data from a multicenter prospective registry of GSR‐ET (German Stroke Registry – Endovascular Treatment) was used. Inclusion criteria and selectivity of SWIFT‐PRIME (Solitaire with the Intention for Thrombectomy as Primary Endovascular Treatment trial), MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands trial), ESCAPE (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times trial), DAWN (DWI or CTP Assessment with Clinical Mismatch in the Triage of Wake‐Up and Late Presenting Strokes Undergoing Neurointervention with Trevo trial) and DEFUSE‐3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke trial) trials were analyzed. Baseline characteristics, procedural and outcome data of patients from GSR‐ET before and after selection were compared with the results of the RCTs. Furthermore, outcome of patients who underwent endovascular treatment despite not fulfilling the RCT criteria was analyzed. A total of 2611 patients were included (median age, 75 years; 49.6% women; median National Institute of Health Stroke Scale, 16). A minority of patients met all inclusion criteria, ranging from 3% (DEFUSE‐3 criteria) to 35% (MR CLEAN criteria). Of the patients fulfilling the MR CLEAN criteria, 41% of patients had a good clinical outcome, compared with 34% of patients that did not fulfill MR CLEAN criteria. Conclusions The RCTs represent a selected population with higher rates of good clinical outcome compared with daily practice. The good outcomes of RCTs can be reproduced in clinical routine in patients who fulfill the RCT inclusion criteria. Furthermore, patients who did not meet the criteria of the RCT still had substantial rates of good clinical outcome.

scholarly journals Efficacy of Mechanical Thrombectomy using Penumbra ACETM Aspiration Catheter Compared to Stent Retriever SolitaireTM FR in Patients with Acute Ischemic Stroke

2021 ◽  
Vol 11 (4) ◽  
pp. 504
Author(s):  
Dalibor Sila ◽  
Markus Lenski ◽  
Maria Vojtková ◽  
Mustafa Elgharbawy ◽  
František Charvát ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Mechanical Thrombectomy ◽  
Binary Logistic Regression ◽  
Stent Retriever ◽  
Good Clinical Outcome ◽  
Significant Difference ◽  
Aspiration Technique

Background: Mechanical thrombectomy is the standard therapy in patients with acute ischemic stroke (AIS). The primary aim of our study was to compare the procedural efficacy of the direct aspiration technique, using Penumbra ACETM aspiration catheter, and the stent retriever technique, with a SolitaireTM FR stent. Secondarily, we investigated treatment-dependent and treatment-independent factors that predict a good clinical outcome. Methods: We analyzed our series of mechanical thrombectomies using a SolitaireTM FR stent and a Penumbra ACETM catheter. The clinical and radiographic data of 76 patients were retrospectively reviewed. Using binary logistic regression, we looked for the predictors of a good clinical outcome. Results: In the Penumbra ACETM group we achieved significantly higher rates of complete vessel recanalization with lower device passage counts, shorter recanalization times, shorter procedure times and shorter fluoroscopy times (p < 0.001) compared to the SolitaireTM FR group. We observed no significant difference in good clinical outcomes (52.4% vs. 56.4%, p = 0.756). Predictors of a good clinical outcome were lower initial NIHSS scores, pial arterial collateralization on admission head CT angiography scan, shorter recanalization times and device passage counts. Conclusions: The aspiration technique using Penumbra ACETM catheter is comparable to the stent retriever technique with SolitaireTM FR regarding clinical outcomes.

Abstract P338: Incidence, Predictors and Impact of Infarct in New Territory in Escape Na1 Trial

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Nishita Singh ◽  
Martha Marko ◽  
Petra Cimflova ◽  
Johanna Ospel ◽  
Nima Kashani ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Endovascular Therapy ◽  
Randomized Study ◽  
Maximum Diameter ◽  
Vascular Territory ◽  
Poor Clinical Outcome ◽  
Guide Catheter ◽  
Ct And Mri

Introduction: Infarct in new territory (INT) is a known complication of endovascular therapy. We assessed the prevalence, predictors and clinical relevance of INT Methods: We included patients from the ESCAPE-NA1: a multicenter, international randomized study that assessed the efficacy of intravenous nerinetide in patients with acute ischemic stroke who underwent EVT within 12 hours from onset. All imaging was re-evaluated, and INT was defined by presence of infarct in new vascular territory, outside the baseline target occlusion(s) on follow up CT and MRI. INT’s were classified by maximum diameter (<2mm, 2-20mm and >20mm) and location. Results: Of 1099 analyzed patients in ESCAPE NA1, 107 had INT (9.7%, mean age 67 years, 51.4% females). There were no differences at baseline in those with vs without INT. Most INTs (75.7%) were angiographically occult and 41(38.3%) were > 20mm. The most common INT territory was the ACA alone or in combination with MCA/PCA (30.3%). The presence of emboli in new territory angiographically was significantly associated with INT (OR 16.39, 95%CI 8.14-33.09). Alteplase use, balloon guide catheter use, nerinetide and initial occlusion site did not predict INT. INT patients had higher final median infarct volumes compared to non-INT (44.5cc vs 23.3cc, P<0.001). Large INT (diameter of >20mm) were associated with poor clinical outcome compared to INT (<2mm) OR (mRS 0-2) 0.17, 95%CI 0.05-0.55). Conclusion: Infarcts in new territory are common and are associated with poor outcome.

Abstract 32: Residual Perfusion Deficit is Common Post Successful EVT and is Associated With Worse Clinical Outcome

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Marie Luby ◽  
Saeed Ansari ◽  
Rachel Davis ◽  
Marc Fisher ◽  
Lawrence Latour ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Mechanical Obstruction ◽  
Perfusion Deficit ◽  
Target Vessel ◽  
Vascular Territory ◽  
Anterior Circulation ◽  
Black African ◽  
Improve Outcome ◽  
Neurological Improvement ◽  
Iv Tpa

Introduction: A significant portion of patients despite achieving successful recanalization following endovascular therapy (EVT) still have some residual perfusion deficit. The objective of this study was to identify the association of residual perfusion deficit with recanalization status and clot presence post EVT. Methods: Patients were included if they were evaluated at one of two comprehensive stroke centers from January 2015 through February 2018, had LVO of the anterior circulation, had baseline MRI pre EVT, and treated with EVT. Independent image reads by two separate readers blinded to target vessel, TICI score, and clinical outcome, evaluated the pre EVT, 2 hours, and 24 hours post EVT MRI for perfusion deficit and clot presence. The MTT and TTP maps post EVT were read separately for residual perfusion deficit, compared to the pre EVT perfusion deficit. Clot presence was read as susceptibility sign on GRE consistent with the vascular territory identified on the pre EVT PWI. Successful recanalization was defined as TICI 2b\3 in the IR suite. Early neurological improvement (ENI) was defined as a reduction of the admit NIHSS by ≥4 points or a score of 0-1 at 24 hours. Results: Fifty-eight patients were included with median age of 58 years, 55% female, 47% Black\African-American, median admit NIHSS of 19, 72% with M1 LVO, 69% treated with IV tPA, 79% achieved TICI of 2b\3, and 52% with ENI at 24 hours. All patients had a perfusion deficit pre EVT with 73% having a corresponding clot on GRE. Following EVT, 76% and 52% of patients had residual perfusion deficit at 2 and 24 hours post EVT, but only 24% and 13%, respectively, still had evidence of clot. For the 46 patients with successful recanalization, 41% still had some residual perfusion deficit at 24 hours, but only 9% still had clot, suggesting inadequate perfusion without a mechanical obstruction. The frequency of ENI at 24 hours was associated with complete reperfusion, 88% versus 46% (p=0.039) at 2 hours post EVT, and 76% versus 33% (p=0.002) at 24 hours post EVT. Conclusions: Residual perfusion deficit on post EVT MRI is common, even with successful recanalization, and is associated with poor outcome. Patients with residual perfusion deficit may benefit from early adjunctive therapy following EVT to improve outcome.

Abstract 3275: Early Neurological Improvement After Intravenous Thrombolysis in Acute Stroke Predicts Long-Term Functional Outcome

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Leonard L Yeo ◽  
Liang Shen ◽  
Ben Wakerley ◽  
Aftab Ahmad ◽  
Kay W Ng ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Symptom Onset ◽  
Functional Outcomes ◽  
Treatment Time ◽  
Favorable Outcome ◽  
Stroke Patients ◽  
Neurological Improvement ◽  
Iv Tpa

Background: Intravenously administered tissue plasminogen activator (IV-TPA) remains the only approved therapeutic agent for arterial recanalization in acute ischemic stroke (AIS). Wide variations in the rates and timing of neurological recovery are observed in thrombolyzed patients. While all IV-TPA treated patients are routinely evaluated for neurological recovery at 24-hours, considerable improvement occurs in some cases within 2-hours of treatment initiation. We evaluated whether early neurological improvement at 2-hours after IV-TPA bolus (ENI-2) can predict functional outcomes in thrombolyzed AIS patients at 3-months. Methods: Data for consecutive stroke patients treated with IV-TPA within 4.5 hours of symptom-onset during 2007-2010 were prospectively entered in the thrombolyzed registry maintained at our tertiary care center. Data were collected for demographic characteristics, vascular risk factors, stroke subtypes and blood pressure levels before IV-TPA bolus. National Institute of Health Stroke Scale (NIHSS) scores were obtained before IV-TPA bolus and at 2-hours. ENI-2 was defined as a reduction in NIHSS score by more than 10-points from baseline score or an absolute score of 4-points or less at 2-hours after IV-TPA bolus. Functional outcomes at 3-months were determined by modified Rankin scale (mRS). Data were analyzed by SPSS 19.0. Results: Of the 2238 AIS patients admitted during the study period, 240 (11%) received IV-TPA within 4.5-hours of symptom-onset. Median age was 65yrs (range 19-92), 63% males, median NIHSS 17points (range 3-35) and median onset-to-treatment time 149 minutes. Overall, 122 (50.8%) patients achieved favorable functional outcome (mRS 0-1) at 3-months. Factors associated with favorable outcome at 3-months on univariable analysis were younger age, female gender, presence of atrial fibrillation, baseline NIHSS, onset-to-treatment time (OTT) and ENI-2. However, multivariable analysis demonstrated NIHSS at onset (OR per 1-point increase 0.907, 95%CI 0.848-0.969) and ENI-2 (OR 4.926 95%CI 1.66-15.15) as independent predictors of favorable outcome at 3-months. Conclusion: Early Neurological improvement at 2-hours after IV-TPA bolus is a strong predictor of the functional outcome at 3-months in acute ischemic stroke patients.

scholarly journals Revascularization of tandem occlusions in acute ischemic stroke: review of the literature and illustrative case

2017 ◽  
Vol 42 (4) ◽  
pp. E15 ◽  
Author(s):  
Nnenna Mbabuike ◽  
Kelly Gassie ◽  
Benjamin Brown ◽  
David A. Miller ◽  
Rabih G. Tawk
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Carotid Occlusion ◽  
Illustrative Case ◽  
Retrograde Approach ◽  
Nihss Score ◽  
Tandem Occlusion ◽  
Pubmed Database

OBJECTIVE Tandem occlusions continue to represent a major challenge in patients with acute ischemic stroke (AIS). The anterograde approach with proximal to distal revascularization as well as the retrograde approach with distal to proximal revascularization have been reported without clear consensus or standard guidelines. METHODS The authors performed a comprehensive search of the PubMed database for studies including patients with carotid occlusions and tandem distal occlusions treated with endovascular therapy. They reviewed the type of approach employed for endovascular intervention and clinical outcomes reported with emphasis on the revascularization technique. They also present an illustrative case of AIS and concurrent proximal cervical carotid occlusion and distal middle cerebral artery occlusion from their own experience in order to outline the management dilemma for similar cases. RESULTS A total of 22 studies were identified, with a total of 790 patients with tandem occlusions in AIS. Eleven studies used the anterograde approach, 3 studies used the retrograde approach, 4 studies used both, and in 4 studies the approach was not specified. In the studies that reported Thrombolysis in Cerebral Infarction (TICI) grades, an average of 79% of patients with tandem occlusions were reported to have an outcome of TICI 2b or better. One study found good clinical outcome in 52.5% of the thrombectomy-first group versus 33.3% in the stent-first group, as measured by the modified Rankin Scale (mRS). No study evaluated the difference in time to reperfusion for the anterograde and retrograde approach and its association with clinical outcome. The patient in the illustrative case had AIS and tandem occlusion of the internal carotid and middle cerebral arteries and underwent distal revascularization using a Solitaire stent retrieval device followed by angioplasty and stent treatment of the proximal cervical carotid occlusion. The revascularization was graded as TICI 2b; the postintervention National Institutes of Health Stroke Scale (NIHSS) score was 17, and the discharge NIHSS score was 7. The admitting, postoperative, and 30-day mRS scores were 5, 1, and 1, respectively. CONCLUSIONS In stroke patients with tandem occlusions, distal to proximal revascularization represents a reasonable treatment approach and may offer the advantage of decreased time to reperfusion, which is associated with better functional outcome. Further studies are warranted to determine the best techniques in endovascular therapy to use in this subset of patients in order to improve clinical outcome.

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