Abstract TP17: Patients Treated With Endovascular Treatment Outside Guidelines

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Claus Z Simonsen ◽  
Mads Rasmussen ◽  
Albert J Yoo ◽  
Leif H Sørensen
Keyword(s):  
Diffusion Weighted Imaging ◽  
Time Window ◽  
Posterior Circulation ◽  
Lesion Volume ◽  
Inclusion Criteria ◽  
Anterior Circulation ◽  
Posterior Circulation Stroke ◽  
Good Outcome ◽  
Diffusion Weighted ◽  
Number Of Patients

Backgroud: The number of Endovascular treatments (EVT) in stroke is increasing rapidly after the publication of the positive trials. Generally, EVT is recommended in anterior circulation large vessel stroke in a 6 hour time window in patients who are independent (modified Rankin scale 2 or less) and if the infarct is not too large (ASPECTS > 4 or diffusion weighted imaging lesion volume <70 cc). Methods: GOLIATH (General Or Local anesthesia in Intra Arterial THerapy) is a study which is testing whether conscious sedation (CS) or general anesthesia (GA) should be recommended during EVT. The inclusion criteria for GOLIATH include those mentioned above and also, patients must have an MRI scan because the primary outcome measure is infarct growth from baseline to 48-72 hours after EVT as measured on diffusion weighted imaging. Included patients are randomized between GA and CS. We have also captured screen failures (i.e., patients who did not fulfil inclusion criteria but who underwent EVT anyway). We compared the number of patients treated in GOLIATH with the number of screen failures from study initiation in March 2015 to August 2016. Results: Eighty-seven patients have been enrolled in GOLIATH. In the same period, 85 patients have been treated with EVT outside of GOLIATH. The reasons for screen failure were: Posterior circulation stroke: 20 patients NIHSS <10: 18 patients Groin puncture > 6 hours: 16 patients CT scan: 16 patients. (Pacemaker, vomiting, metallic foreign bodies or implants) Intubated at arrival: 5 patients Infarct > 70 cc: 3 patients Baseline mRS >2: 2 patients Age <18 years: 2 patients Withdrew consent: 1 patient Deemed unsafe by anesthesiologist: 2 patients Discussion: Among the first 69 patients in GOLIATH, 45 (65%) achieved a good outcome and 6 (9%) were dead at 90 days. Among the first 58 screen failures, 21 (36%) achieved a good outcome and 16 (28%) were dead at 90 days (p=0.002 for good outcome and p=0.01 for death, Chi-square test). Conclusion: A high number of patients are treated outside the general guidelines. Trials are needed to demonstrate effect is these subgroups. (Posterior circulation stroke, NIHSS <10 and groin puncture >6 hours.)

Novel Diffusion-Weighted Imaging Score Showed Good Prognostic Value for Acute Basilar Artery Occlusion Following Endovascular Treatment: The Pons-Midbrain and Thalamus Score

Stroke ◽  
2021 ◽  
Author(s):  
Lian Liu ◽  
Meiping Wang ◽  
Yiming Deng ◽  
Gang Luo ◽  
Xuan Sun ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Acute Stroke ◽  
Brain Stem ◽  
Basilar Artery ◽  
Diffusion Weighted Imaging ◽  
Artery Occlusion ◽  
Posterior Circulation ◽  
Basilar Artery Occlusion ◽  
Good Outcome ◽  
Diffusion Weighted

Background and Purpose: Prognostic factors for outcome of endovascular treatment remains to be investigated in patients with acute basilar artery occlusion. We aimed to assess the prognostic value of a novel pretreatment diffusion-weighted imaging score: The Pons-Midbrain and Thalamus (PMT) score. Methods: Eligible patients who underwent endovascular treatment due to acute basilar artery occlusion were reviewed. The PMT score was a diffusion-weighted imaging–based semiquantitative scale in which the infarctions of pons, midbrain, and thalamus were fully considered. The PMT score was assessed as well as the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score and Brain Stem Score. Good outcomes were defined as a modified Rankin Scale score of ≤3 at 90-day and successful reperfusion as Thrombolysis in Cerebral Infarction grades 2b/3. The associations between baseline clinical parameters and good outcomes were evaluated with logistic regression. Results: A total of 107 patients with pretreatment magnetic resonance imaging were included in this cohort. The baseline PMT score (median [interquartile range], 3 [1–5] versus 7 [5–9]; P <0.001) and Brain Stem Score (median [interquartile range], 2 [1–4] versus 3 [2–5]; P =0.001) were significantly lower in good outcome group; the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score was higher in good outcome group without statistical significance. As a result of receiver operating characteristic curve analyses, the posterior circulation Acute Stroke Prognosis Early Computed Tomography Score showed poor prognostic accuracy for good outcome (area under the curve, 0.60 [95% CI, 0.49–0.71]; P =0.081); The baseline PMT score showed significantly better prognostic accuracy for 90-day good outcome than the Brain Stem Score and National Institutes of Health Stroke Scale (area under the curve, 0.80 versus 0.68 versus 0.78, P =0.003). In addition, favorable PMT score <7 (odds ratio, 22.0 [95% CI, 6.0–80.8], P <0.001), Brain Stem Score <3 (odds ratio, 4.65 [95% CI, 2.05–10.55], P <0.001) and baseline National Institutes of Health Stroke Scale <23 (odds ratio, 8.0 [95% CI, 2.5–25.6], P <0.001) were associated with improved good outcome. Conclusions: In patients with acute basilar artery occlusion following endovascular treatment, the pretreatment diffusion-weighted imaging based PMT score showed good prognostic value for clinical outcome.

scholarly journals Late Thrombectomy in Clinical Practice

2021 ◽  
Author(s):  
Moriz Herzberg ◽  
Korbinian Scherling ◽  
Robert Stahl ◽  
Steffen Tiedt ◽  
Frank A. Wollenweber ◽  
...  
Keyword(s):  
Clinical Practice ◽  
Clinical Outcome ◽  
Perfusion Imaging ◽  
Time Window ◽  
Ct Perfusion ◽  
Large Trial ◽  
Real World Data ◽  
Baseline Trial ◽  
Good Outcome ◽  
Number Of Patients

Abstract Background and Purpose To provide real-world data on outcome and procedural factors of late thrombectomy patients. Methods We retrospectively analyzed patients from the multicenter German Stroke Registry. The primary endpoint was clinical outcome on the modified Rankin scale (mRS) at 3 months. Trial-eligible patients and the subgroups were compared to the ineligible group. Secondary analyses included multivariate logistic regression to identify predictors of good outcome (mRS ≤ 2). Results Of 1917 patients who underwent thrombectomy, 208 (11%) were treated within a time window ≥ 6–24 h and met the baseline trial criteria. Of these, 27 patients (13%) were eligible for DAWN and 39 (19%) for DEFUSE3 and 156 patients were not eligible for DAWN or DEFUSE3 (75%), mainly because there was no perfusion imaging (62%; n = 129). Good outcome was not significantly higher in trial-ineligible (27%) than in trial-eligible (20%) patients (p = 0.343). Patients with large trial-ineligible CT perfusion imaging (CTP) lesions had significantly more hemorrhagic complications (33%) as well as unfavorable outcomes. Conclusion In clinical practice, the high number of patients with a good clinical outcome after endovascular therapy ≥ 6–24 h as in DAWN/DEFUSE3 could not be achieved. Similar outcomes are seen in patients selected for EVT ≥ 6 h based on factors other than CTP. Patients triaged without CTP showed trends for shorter arrival to reperfusion times and higher rates of independence.

scholarly journals Intravenous thrombolysis outcome in posterior vs anterior circulation stroke in a tertiary stroke center in Egypt

2021 ◽  
Vol 57 (1) ◽  
Author(s):  
Nourhan Abdelmohsen Taha ◽  
Hala El Khawas ◽  
Mohamed Amir Tork ◽  
Tamer M. Roushdy
Keyword(s):  
Intravenous Thrombolysis ◽  
Posterior Circulation ◽  
University Hospitals ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Time Points ◽  
Posterior Circulation Stroke ◽  
First Line Therapy ◽  
Insignificant Difference ◽  
Stroke Center

Abstract Background Intravenous thrombolysis (IVT) with alteplase is the first-line therapy for acute ischemic anterior and posterior circulation strokes (ACS and PCS). Knowledge about safety and efficacy of IVT in posterior circulation stroke is deficient as most of the Egyptian studies either assessed IVT outcome in comparison to conservative therapy or its outcome in anterior circulation stroke only. Therefore, our aim was to compare the relative frequency and outcome after intravenous thrombolysis in anterior versus posterior circulation stroke patients presenting to stroke centers of Ain Shams University hospitals (ASUH). Results A total of 238 anterior circulation stroke and 61 posterior circulation strokes were enrolled, onset-to-door and door-to-needle time were statistically insignificant. NIHSS showed comparable difference at all time points despite higher scores along anterior circulation stroke; 90-day modified Rankin Scale (mRS) showed significant improvement in both groups from mRS >2 to ≤2 with a better percentage along posterior circulation stroke patients. There was insignificant difference for either incidence of death or intracranial hemorrhage (ICH) between the two groups. Conclusion IVT significantly reduced NIHSS for both anterior and posterior circulation stroke along different studied time points. Meanwhile, a higher percentage of patients with posterior circulation stroke had a better mRS outcome at 90 days.

scholarly journals Novel selection paradigms for endovascular stroke treatment in the extended time window

2021 ◽  
pp. jnnp-2020-325284
Author(s):  
Mehdi Bouslama ◽  
Diogo C Haussen ◽  
Gabriel Rodrigues ◽  
Clara Barreira ◽  
Michael Frankel ◽  
...  
Keyword(s):  
Time Window ◽  
Ct Perfusion ◽  
Clinical Aspects ◽  
Anterior Circulation ◽  
Stroke Treatment ◽  
Good Outcome ◽  
Potential Alternative ◽  
The Right ◽  
Contrast Ct ◽  
Selection Methodology

Background and purposeThe optimal selection methodology for stroke thrombectomy beyond 6 hours remains to be established.MethodsReview of a prospectively collected database of thrombectomy patients with anterior circulation strokes, adequate CT perfusion (CTP) maps, National Institute of Health Stroke Scale (NIHSS)≥10 and presenting beyond 6 hours from January 2014 to October 2018. Patients were categorised according to five selection paradigms: DAWN clinical-core mismatch (DAWN-CCM): between age-adjusted NIHSS and CTP core, DEFUSE 3 perfusion imaging mismatch (DEFUSE-3-PIM): between CTP-derived perfusion defect (Tmax >6 s lesion) and ischaemic core volumes and three non-contrast CT Alberta Stroke Program Early CT Score (ASPECTS)-based criteria: age-adjusted clinical-ASPECTS mismatch (aCAM): between age-adjusted NIHSS and ASPECTS, eloquence-adjusted clinical ASPECTS mismatch (eCAM): ASPECTS 6–10 and non-involvement of the right M6 and left M4 areas and standard clinical ASPECTS mismatch (sCAM): ASPECTS 6–10.Results310 patients underwent analysis. DEFUSE-3-PIM had the highest proportion of qualifying patients followed by sCAM, eCAM, aCAM and DAWN-CCM (93.5%, 92.6%, 90.6%, 90% and 84.5%, respectively). Patients meeting aCAM, eCAM, sCAM and DAWN-CCM criteria had higher rates of 90-day good outcome compared with their non-qualifying counterparts(43.2% vs 12%,p=0.002; 42.4% vs 17.4%, p=0.02; 42.4% vs 11.2%, p=0.009; and 43.7% vs 20.5%, p=0.007, respectively). There was no difference between patients meeting DEFUSE-3-PIM criteria versus not(40.8% vs 31.3%,p=0.45). In multivariate analysis, all selection modalities except for DEFUSE-3-PIM were independently associated with 90-day good outcome.ConclusionsASPECTS-based selection paradigms for late presenting and wake-up strokes ET have comparable proportions of qualifying patients and similar 90-day functional outcomes as DAWN-CCM and DEFUSE-3-PIM. They also might lead to better outcome discrimination. These could represent a potential alternative for centres where access to advanced imaging is limited.

Abstract WP5: Outcomes Are Not Different Between Patients With Intermediate and High Dwi-aspects After Stent-retriever Thrombectomy

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Woong Yoon ◽  
Seul Kee Kim ◽  
Tae Wook Heo ◽  
Byung Hyun Baek ◽  
Jaechan Park
Keyword(s):  
Functional Outcome ◽  
Time Window ◽  
Multivariate Logistic Regression Analysis ◽  
Area Under The Curve ◽  
Stent Retriever ◽  
Operating Characteristics ◽  
Anterior Circulation ◽  
Good Outcome ◽  
Characteristics Analysis ◽  
The Impact

Introduction: Few studies have investigated the association between pretreatment DWI-ASPECTS and functional outcome after stent-retriever thrombectomy in patients with acute anterior circulation stroke. Hypothesis: Patients with acute stroke and DWI-ASPECTS <7 might have a similar chance of a good outcome compared to those with a higher DWI-ASPECTS, if they are treated with a stent-retriever thrombectomy in a short time window. However, this hypothesis has not been tested. Thus, this study aimed to investigate the impact of DWI-ASPECTS on functional outcome in patients with acute anterior circulation stroke who received a stent-retriever thrombectomy. Methods: We retrospectively analyzed the clinical and DWI data from 171 patients with acute anterior circulation stroke who were treated with stent-retriever thrombectomy within 6 hours of symptom onset. The DWI-ASPECTS was assessed by two readers. A good outcome was defined as a modified Rankin Scale score of 0-2 at 3 months. Results: The median DWI-ASPECTS was 7 (interquartile range, 6-8). Receiver operating characteristics analysis revealed an ASPECTS ≥ 7 was the optimal cut-off to predict a good outcome at 3 months (area under the curve=0.57; sensitivity, 75.3%; specificity, 34.4%). The rates of good outcome, symptomatic hemorrhage, and mortality were not different between high DWI-ASPECTS (scores of 7-10) and intermediate (scores of 4-6) groups. In patients with an intermediate DWI-ASPECTS, good outcome was achieved in 46.5% (20/43) of patients with successful revascularization (modified TICI 2b or 3), whereas no patients without successful revascularization had a good outcome ( P =0.016). In multivariate logistic regression analysis, independent predictors of good outcome were age and successful revascularization. Conclusions: Our study suggested that treatment outcomes were not different between patients with a high DWI-ASPECTS and those with an intermediate DWI-ASPECTS who underwent stent-retriever thrombectomy for acute anterior circulation stroke. Thus, patients with an intermediate DWI-ASPECTS otherwise eligible for endovascular therapy should not be excluded for stent-retriever thrombectomy or stroke trials.

scholarly journals Prediction of secondary ischemic lesions with diffusion-weighted imaging after transient middle cerebral artery occlusion in rats

Stroke ◽  
2001 ◽  
Vol 32 (suppl_1) ◽  
pp. 352-352
Author(s):  
Fuhai Li ◽  
Matthew D Silva ◽  
Xiangjun Meng ◽  
Christopher H Sotak ◽  
Marc Fisher
Keyword(s):  
Middle Cerebral Artery ◽  
Middle Cerebral Artery Occlusion ◽  
Cerebral Artery ◽  
Diffusion Weighted Imaging ◽  
Artery Occlusion ◽  
Lesion Volume ◽  
Diffusion Weighted ◽  
Adc Values ◽  
Cerebral Artery Occlusion ◽  
Initial Lesions

P75 Background and Purpose: Previous studies demonstrated that secondary ischemic lesions documented by diffusion-weighted imaging might be smaller than, larger than or similar to initial lesions that occur during ischemia. The purpose of this study was to investigate if the size of secondary lesions can be predicted. Methods: Twelve rats underwent 30 minutes of transient middle cerebral artery occlusion with the intraluminal suture method. Diffusion- and perfusion-weighted images were performed just before reperfusion, 90 minutes and 24 hours after reperfusion. The ischemic lesion size was calculated by tracing visual abnormalities on the apparent diffusion coefficient (ADC) maps. Cerebral blood flow index (CBF i ) ratio was calculated by dividing the ipsilateral CBF i by the contralateral CBF i . Based on difference between initial and secondary lesion volume, rats were assigned to reperfusion-benefit group (n=6) where secondary lesions were smaller than initial lesions (less than 85% of initial lesions) and reperfusion-nonbenefit group (n=6) where secondary lesions were similar to or larger than initial lesions (more than 85% of initial lesions). Results: At 90 minutes after reperfusion, the initial ischemic lesions almost disappeared in both groups. At 24 hours, secondary lesions were 54±11% (mean±SD) of the initial lesions in the reperfusion-benefit group and 100±14% of the initial lesions in the reperfusion-nonbenefit group (p<0.001). There was no difference in ADC values (47±2×10 -5 mm 2 /s vs 46±5×10 -5 mm 2 /s, p=0.7) and CBF i ratio (0.62±0.06 vs 0.67±0.04, p=0.2) between the two groups before reperfusion. However, the initial lesion volume was significantly smaller in the reperfusion-benefit group than in the reperfusion-nonbenefit group (125±54 mm 3 vs 195±36 mm 3 , p=0.037). Conclusions: Changes of ADC values and CBF before reperfusion are unable to predict if initial ischemic lesions will eventually shrink or not after reperfusion. Smaller size of initial lesions may suggest that secondary lesions will be smaller than initial lesions.

Abstract WP39: Mechanical Embolectomy for Acute Ischemic Stroke Beyond Six Hours From Symptom Onset Using Advanced MR Imaging

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ryan McTaggart ◽  
Shadi Yaghi ◽  
Daniel C Sacchetti ◽  
Richard Haas ◽  
Shawna Cutting ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Mr Imaging ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Lesion Volume ◽  
Large Artery ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome

Background: There is very limited data on the use of advanced neuroimaging to select patients with acute ischemic stroke and large vessel occlusion for intraarterial therapy beyond 6 hours from onset. Our aim is to report the outcome of patients with acute ischemic stroke and large artery occlusion who presented beyond 6 hours from onset, had favorable MRI imaging profile, and underwent mechanical embolectomy. Methods: This is a single institution retrospective study between December 1st, 2015, and July 30 th , 2016 with acute ischemic stroke and anterior circulation large vessel occlusion (LVO) with ASPECTS of 6 or more and beyond 6 hours from symptoms onset. Favorable imaging profile was defined as 1) DWI lesion volume (as defined as apparent diffusion coefficient < 620 X 10-6 mm2/s) of 70 mL or less AND 2) Penumbra volume (as defined by volume of tissue with Tmax >6 sec) of 15 mL or greater AND 3) A mismatch ratio of 1.8 or more AND 4) Volume of tissue with perfusion lesion with Tmax > 10 sec is less than 100 mL. Good outcome was defined as a 90 day mRS≤2. Results: In the study period, 41 patients met the inclusion criteria; 22 (53.6%) had favorable imaging profile and underwent mechanical embolectomy. The median age was 75 years (59-92), 68.2% were females; the median time from last known normal to groin puncture was 684.5 minutes (range 363-1628) and the median admission NIHSS score was 17.5 (range 4-28). The rate of good outcomes in this series was similar to that in a patient level pooled meta-analysis of the recent endovascular trials (68.2% vs. 46.0%, p=0.07). The rate of good outcome matches that of the EXTEND-IA trial that selected patients using perfusion imaging (68.2% vs. 71.0%, p = 1.00). None of the patients in our cohort had symptomatic intracereberal hemorrhage. Conclusion: Advanced MR imaging may help select patients with acute ischemic stroke and anterior circulation large vessel occlusion for embolectomy beyond the treatment window used in most endovascular trials.

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