Abstract TP36: Collaterals Negate Time: Topography and Determinants of Baseline ASPECTS in STRATIS

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
David S Liebeskind ◽  
Graham W Woolf ◽  
Nils Mueller-Kronast ◽  
M A Aziz-Sultan ◽  
Michael T Froehler ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Large Scale ◽  
Arterial Occlusion ◽  
Internal Capsule ◽  
Time Duration ◽  
Anterior Circulation ◽  
Ischemic Lesion ◽  
Lenticular Nuclei ◽  
Selection For

Background: ASPECTS is routinely used to estimate ischemic lesion burden in acute stroke, yet the topography and influence of collaterals has been unexplored. Imaging selection for endovascular therapy in various time epochs may also be simplified with ASPECTS. We leveraged the large-scale registry data of STRATIS to discern the role of collaterals, time and other factors in ASPECTS topography at baseline. Methods: The STRATIS Imaging Core Lab, blind to all clinical data, independently determined ASPECTS scores and regional involvement in anterior circulation occlusions. Collateral status on baseline angiography was scored by ASITN grade. Statistical analyses described ASPECTS regional involvement or topography based on arterial occlusion site and other variables available prior to intervention, determining the influence of collaterals and time duration from onset to imaging. Results: Baseline ASPECTS (n=573) was median 8.0 (2, 10). ASPECTS regions involved were lenticular nuclei 62.3% (357/573), insula 42.2% (242/573), caudate 23.4% (134/573), M2 13.6% (78/573), M4 9.4% (54/573), M5 9.2% (53/573), M1 4.0% (23/573), M3 2.1% (12/573), M6 1.9% (11/573) and internal capsule 0.2% (1/573). Distinct patterns or topography differentiated ICA, M1 and M2 arterial occlusion sites at angiography. Overall, higher ASPECTS (7-10 vs. ≤ 6) was linked with more robust collaterals (p<0.001) and shorter duration from onset to CT (p=0.001), yet collateral grade was unrelated to time. Ordinal multivariate logistic regression on ASPECTS containing collateral grade and time (from onset to CT) as covariates demonstrated that they were significantly associated (p<0.001 and p=0.0024, respectively) with ASPECTS. Conclusions: ASPECTS topography and the extent of ischemic changes are a product of arterial occlusion site, collateral status and time duration. ASPECTS may infer collateral status, a pivotal determinant of outcome in endovascular therapy, irrespective of time from symptom onset.

Abstract 37: ASPECTS and Stratified Outcomes After Endovascular Therapy in the Trevo Retriever Registry: Benefit in Low ASPECTS

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
David S Liebeskind ◽  
Graham W Woolf ◽  
Bin Xiang ◽  
Ryan Shields ◽  
Erol Veznedaroglu ◽  
...  
Keyword(s):  
Endovascular Therapy ◽  
Large Scale ◽  
Arterial Occlusion ◽  
Routine Practice ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Large Scale Data ◽  
Wide Range ◽  
Therapy Studies ◽  
Occlusion Effect

Background: Most endovascular stroke therapy studies and subsequent guidelines restrict intervention based on ASPECTS. A wide range of ASPECTS scores may be encountered in practice and individual patient benefit may be realized even at low ASPECTS. We examined large-scale data on outcomes after endovascular therapy, stratified by baseline ASPECTS in the Trevo Retriever Registry. Methods: The independent Imaging Core Lab of the Trevo Retriever Registry prospectively determines ASPECTS on baseline imaging acquired immediately prior to endovascular thrombectomy. ASPECTS scores and regional involvement were analyzed with respect to site of arterial occlusion, effect of time from symptom onset, co-morbidities and clinical outcomes, based on ASPECTS strata. Results: Baseline ASPECTS data was reviewed by the Imaging Core Lab in 426 subjects with anterior circulation stroke enrolled in the Trevo Retriever Registry, as of July 2016. Mean age was 68.8 ± 13.7 yrs, with 20.9% > 80 years old. Baseline NIHSS was median 15.0 (10.0, 19.0). Onset to CT was median 3.8 (1.5, 9.0) hrs, with median ASPECTS of 8.0 (7.0, 9.0), ranging from 3-10. Baseline ASPECTS 0-7 occurred in 118/426 (27.7%) subjects, including 39.0% of ICA, 27.1% M1 and 16.9% M2/3 arterial occlusions at angiography. Baseline clinical variables predicting ASPECTS included age and NIHSS, whereas the ASPECTS score was mildly associated with final TICI2C reperfusion (r=0.24, p<0.001). Subsequent symptomatic ICH was 1.7% with baseline ASPECTS 0-7 versus 2.0% with ASPECTS 8-10. The distribution of mRS at 90 days based on individual ASPECTS strata from 10 to 3 revealed a trend to worse outcomes with lower ASPECTS, yet good outcomes (mRS 0-2) were 60.7% (ASPECTS 10), 55.3% (9), 60.2% (8), 54.9% (7), 55.1% (3-6). Conclusions: Discrete ASPECTS strata may influence outcomes of endovascular therapy conducted in routine practice around the world, yet individuals with low ASPECTS may still achieve reasonable outcomes.

Abstract W P11: A Clinical Scale to Predict Futile Arterial Recanalization in Acute Stroke Patients with Anterior Circulation Arterial Occlusion Treated with Endovascular Therapies.

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Natalia Perez de la Ossa ◽  
Maria Hernández-Pérez ◽  
Monica Millán ◽  
Meritxell Gomis ◽  
Elena López-Cancio ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Scale Score ◽  
Endovascular Therapy ◽  
Univariate Analysis ◽  
Arterial Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
History Of ◽  
Stent Retrievers ◽  
Arterial Recanalization

Introduction: Futile arterial recanalization (FAR), considered as a lack of functional recovery despite complete recanalization, is observed in up to 30-50% of acute stroke patients treated with endovascular therapy. We aimed to develop a prognostic scale based on baseline clinical and radiological factors to predict FAR. Methods: Prospective analysis of consecutive stroke patients with anterior circulation occlusion treated with endovascular therapy (97% mechanical thrombectomy with stent-retrievers). Complete recanalization was considered as a TICI 2b-3. FAR was defined as a modified Rankin scale >2 at 90 days in patients with complete recanalization. Baseline factors associated with FAR were detected on univariate analysis and were used to compose the predictive scale. Results: From a total of 229 patients with anterior arterial occlusion, 166 (72.5%) achieved complete recanalization. FAR was observed in 80/166 (48.2%). Factors significantly associated with FAR were included to compose the predictive scale as follow: Age (scoring 0 if ≤70 and 1 if >70 years old), history of diabetes mellitus (0 if absent, 1 if present), history of hypertension (0 if absent, 1 if present), NIHSS (1 if NIHSS ≤10, 2 if NIHSS 10-19, 3 if NIHSS>19), ASPECTS (1 if ASPECTS 9-10, 2 if ASPECTS 7-8, 3 if ASPECTS<7) and i.v tPA use (0 if yes, 1 if not). The higher the scale score, the higher the risk of FAR (Figure). The scale showed a good predictive value of FAR (c-statistics 0.71). A scale score <5 was associated with a low rate of FAR (25%) whereas a score >7 increased FAR up to 86%. Conclusion: We developed a simple scale that can easily predict futile arterial recanalization (FAR) in stroke patients with large arterial occlusion treated with endovascular therapies. A larger validation study is necessary to confirm the utility of this predictive scale.

The role of ASPECTs in patient selection for endovascular therapy – CTA source images versus noncontrast CT

2020 ◽  
Vol 73 ◽  
pp. 195-200
Author(s):  
Atilla Özcan Özdemir ◽  
Ezgi Sezer Eryıldız ◽  
Fatma Ger Akarsu ◽  
Zehra Uysal Kocabaş ◽  
Özlem Aykaç
Keyword(s):  
Patient Selection ◽  
Endovascular Therapy ◽  
Noncontrast Ct ◽  
Selection For

Abstract 105: Time for Collaterals? Evidence from 695 Endovascular Therapy Cases for Acute Stroke in ENDOSTROKE

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
David S Liebeskind ◽  
Joachim Berkefeld ◽  
Christian H Nolte ◽  
Georg Bohner ◽  
Kurt Niederkorn ◽  
...  
Keyword(s):  
Median Time ◽  
Endovascular Therapy ◽  
Clinical Information ◽  
Routine Practice ◽  
Anterior Circulation ◽  
Angiographic Data ◽  
Procedural Time ◽  
Grade 3 ◽  
Time Required

Background: Recent stroke clinical trials demonstrate the profound impact of collaterals, yet time constraints are often cited as rationale for not evaluating or imaging collaterals prior to endovascular therapy (EVT). We examined the role of collaterals on patient outcomes in a large registry of EVT, analyzing actual time required to obtain such data before treatment of various occlusion sites and monitoring for potential harm. Methods: ENDOSTROKE is an industry-independent, centrally-monitored multicenter registry evaluating EVT in routine clinical practice. Central reading of angiographic data blinded to clinical information was performed by the core lab in 695 patients assessing TICI scores, ASITN collateral grade and detailed procedural time metrics. Results: 75% had anterior circulation strokes (including 270 proximal MCA, 106 ICAT, 90 cICA occlusions) and 25% posterior circulation strokes (including 148 basilar artery occlusions). Assessment of ASITN collateral grade was possible in 511 (73%) of patients; in 184 (27%) collateral status was not obtained prior to therapeutic intervention. Median time from initial angiography and first evidence of TICI 2A reperfusion was only one minute longer in patients with available ASITN scores than in those without (38 min (23, 61) vs. 37 (22, 55), p=0.552) and time-differences were even smaller in anterior circulation strokes (median time 37 min in both groups). In vertebrobasilar occlusion, this time metric was 5 minutes longer in those with available ASITN scores (39 min (24, 39)) than in those without (34 min (23, 52), p=0.357). Of those with ASITN available, patients with grade 3-4 had much better outcomes (48% 0-2 90-day mRS) than patients with grade 0-2 (30%, p<0.0001). No excess in complication rate (i.e. dissection, thrombemboli) was noted in the cohort with available ASITN. Conclusions: Collaterals have a dramatic association with clinical outcomes in the largest endovascular study to date. In routine practice, EVT outcomes across various occlusion sites are strongly influenced by collateral grade. Negligible time of only a few minutes is typically required to obtain such essential data prior to treatment with no cost of incremental harm.

Abstract TMP4: Serial ASPECTS from Baseline to 24 Hours: Impact of Endovascular Therapy in STRATIS

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
David S Liebeskind ◽  
Graham W Woolf ◽  
Nils H Mueller-Kronast ◽  
M A Aziz-Sultan ◽  
Michael T Froehler ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Data ◽  
Endovascular Therapy ◽  
Large Scale ◽  
Surrogate Endpoint ◽  
Statistical Analyses ◽  
Registry Data ◽  
Clinical Predictors ◽  
Anterior Circulation ◽  
Stroke Lesion

Background: Serial ASPECTS of ischemic stroke lesion evolution from baseline to 24-hours has been established as an effective surrogate endpoint in endovascular therapy. The use of this imaging shift has not been implemented beyond thrombectomy trials to estimate impact of endovascular therapy in large-scale registry data. Methods: The STRATIS Imaging Core Lab, blind to all clinical data, independently determined ASPECTS scores on baseline and 24-hour studies. ASPECTS regional involvement and resulting total scores were analyzed in anterior circulation occlusions in STRATIS. Statistical analyses calculated the proportion of subjects with 0 ASPECTS score shift and separately, those with shifts >4, 5, 6 points. Clinical predictors of ASPECTS shift and regional involvement were determined. Results: Baseline ASPECTS (n=517) was 8.2 ± 1.59 (median 8.0 (2, 10)) and 24-hour ASPECTS (n=547) was 6.0 ± 2.92 (median 7.0 (0, 10)). Serial ASPECTS (n=487) revealed change of -2.1 ± 2.41 (median-1.0 (-10, 3)). Absolutely no change in ASPECTS, or 0 shift from baseline to 24 hours, occurred in 157/487 (32%). Substantial ASPECTS decline of ≥4 occurred in 117/487 (24%), with ≥5 in 76/487 (16%) and ≥6 in 51/487 (10%). ASPECTS decline was linked with baseline collaterals (ASITN 4 (n=19; -0.9 ± 1.05); 3 (n=117; -0.8 ± 1.21); 2 (n=140; -2.6 ± 2.27); 1 (n=29; -3.6 ± 2.34); 0 (n=10; -4.2 ± 3.08)) and the degree of subsequent reperfusion (oTICI 3 (n=63; -1.1 ± 1.94); 2B (n=282; -1.9 ± 2.32); 2A (n=103; -3.4 ± 2.38); 1 (n=2; -3.0 ± 1.41); 0 (n=10; -4.0 ± 2.75)). Baseline predictors of ≥6 ASPECTS decline included previous TIA (OR 3.10 (95%CI 1.32, 7.31), diabetes (OR 2.23 (95%CI 1.22, 4.07)) and baseline NIHSS (OR 1.10 (95%CI 1.03, 1.16). Conclusions: Frozen ASPECTS or 0 shift from baseline to 24 hours occurs in about 1/3 of all cases treated with endovascular therapy in a large-scale registry. Poor collaterals, prior TIA, diabetes and elevated baseline NIHSS may be important predictors of those likely to experience infarct evolution despite reperfusion, identifying optimal candidates for neuroprotection with endovascular therapy.

scholarly journals The value of teaching increases with tool complexity in cumulative cultural evolution

2020 ◽  
Vol 287 (1939) ◽  
pp. 20201885
Author(s):  
Amanda J. Lucas ◽  
Michael Kings ◽  
Devi Whittle ◽  
Emma Davey ◽  
Francesca Happé ◽  
...  
Keyword(s):  
Cultural Evolution ◽  
Large Scale ◽  
Learning Processes ◽  
Cumulative Culture ◽  
Evolutionary Force ◽  
Selection For ◽  
Cumulative Cultural Evolution ◽  
Social Learning Processes ◽  
Tool Types

Human cumulative cultural evolution (CCE) is recognized as a powerful ecological and evolutionary force, but its origins are poorly understood. The long-standing view that CCE requires specialized social learning processes such as teaching has recently come under question, and cannot explain why such processes evolved in the first place. An alternative, but largely untested, hypothesis is that these processes gradually coevolved with an increasing reliance on complex tools. To address this, we used large-scale transmission chain experiments (624 participants), to examine the role of different learning processes in generating cumulative improvements in two tool types of differing complexity. Both tool types increased in efficacy across experimental generations, but teaching only provided an advantage for the more complex tools. Moreover, while the simple tools tended to converge on a common design, the more complex tools maintained a diversity of designs. These findings indicate that the emergence of cumulative culture is not strictly dependent on, but may generate selection for, teaching. As reliance on increasingly complex tools grew, so too would selection for teaching, facilitating the increasingly open-ended evolution of cultural artefacts.

Effect of Endovascular Therapy on Subsequent Decompressive Hemicraniectomy in Cardioembolic Ischemic Stroke with Proximal Intracranial Occlusion in the Anterior Circulation: Sub-Analysis of the RESCUE-Japan Registry 2

2019 ◽  
Vol 48 (1-2) ◽  
pp. 9-16 ◽  
Author(s):  
Hidetoshi Matsukawa ◽  
Yoshihiro Kiura ◽  
Nobuyuki Sakai ◽  
Hiroshi Yamagami ◽  
Kazutaka Uchida ◽  
...  
Keyword(s):  
Intracranial Hemorrhage ◽  
Endovascular Therapy ◽  
Functional Limitation ◽  
Severe Disabilities ◽  
Lesion Size ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Ischemic Lesion ◽  
Decompressive Hemicraniectomy ◽  
Symptomatic Intracranial Hemorrhage

Background: Cardioembolic stroke is associated with a higher rate of functional limitation, which may be related to the larger ischemic lesion size. Endovascular therapy (EVT) for acute stroke caused by large vessel occlusion reduces severe disabilities. Objectives: We aimed to investigate the relationship between EVT and decompressive hemicraniectomy (DH) in patients with cardioembolic proximal intracranial occlusion in the anterior circulation (CPIOAC) using the data from the Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan Registry 2. Methods: Among 2,420 patients in the RESCUE-Japan Registry 2, 555 patients aged 20–80 years with acute cardioembolic occlusion of the internal carotid artery and/or the first segment of the middle cerebral artery were included. The primary outcome was DH. Secondary outcomes were any type of intracranial hemorrhage, symptomatic intracranial hemorrhage indicating neurological worsening of >4 points on the National Institutes of Health Stroke Scale within 72 h after the onset of stroke, and recurrence of stroke or transient ischemic attack (TIA) within 90 days. Results: The median age was 73 years (66–77 years), and 360 patients (65%) were male. DH was performed in 1 of 374 patients in the EVT group and 5 of 181 patients in the no-EVT group (p = 0.032). The incidence of any type of intracranial hemorrhage and symptomatic intracranial hemorrhage within 72 h and recurrence of stroke or TIA within 90 days were similar between both groups. Conclusions: EVT may reduce DH in patients with CPIOAC without increasing intracranial hemorrhage.

Endovascular therapy for anterior circulation large vessel occlusion in telestroke

2019 ◽  
pp. 1357633X1986719 ◽  
Author(s):  
Haidar Moustafa ◽  
Kristian Barlinn ◽  
Alexandra Prakapenia ◽  
Simon Winzer ◽  
Johannes Gerber ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Endovascular Therapy ◽  
Favourable Outcome ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Symptomatic Intracerebral Haemorrhage

Introduction Recent exploratory analysis suggested comparable outcomes among stroke patients undergoing endovascular therapy (EVT) for anterior circulation large vessel occlusion, whether selected via the telestroke network or admitted directly to an EVT-capable centre. We further studied the role of telemedicine in selection of ischaemic stroke patients potentially eligible for EVT. Methods We prospectively included consecutive ischaemic stroke patients with anterior circulation large vessel occlusion who underwent EVT at our neurovascular centre (January 2016 to March 2018). We compared safety and efficacy including symptomatic intracerebral haemorrhage (sICH), successful reperfusion (mTICI 2b/3), 90-day favourable outcome (mRS ≤ 2) and 90-day survival between patients transferred from telestroke hospitals and patients directly admitted. Results Of 280 potentially EVT-eligible patients, 72/129 (56%) telestroke and 91/151 (60%) direct admissions eventually underwent EVT (age 76 (66–82) years, median (interquartile range), 46% men, NIHSS score 17 (13–20)). Telestroke patients had larger pre-EVT infarct cores (ASPECTS: 7 (6–8) vs. 8 (7–9); p < 0.0001) and shorter door-to-groin puncture times (71 (56–84) vs. 101 (79–133) min; p < 0.0001) than directly admitted patients. sICH (2.8% vs. 1.1%; p = 0.58), successful reperfusion (81% vs. 77%; p = 0.56), 90-day favourable outcome (25% vs. 29%; p = 0.65) and 90-day survival (73% vs. 67%; p = 0.39) rates were comparable among telestroke and direct admissions. Discussion Our data underpins the important role of telemedicine in identifying acute ischaemic stroke patients lacking immediate access to EVT-capable stroke centres. Stroke patients selected via telemedicine and those directly admitted had comparable chances of favourable outcomes after EVT for large vessel occlusion.

Abstract TP28: Combining Clinical with Radiographic Criteria to Select Patients for Endovascular Therapy in Acute Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Aaron W Grossman ◽  
ReneéL Martin ◽  
Thomas A Tomsick ◽  
Pooja Khatri ◽  
Joseph P Broderick
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Therapy ◽  
Predictive Value ◽  
Arterial Occlusion ◽  
Interventional Treatment ◽  
Stroke Severity ◽  
Anterior Circulation ◽  
Head Ct ◽  
Sensitivity Specificity ◽  
Iv Tpa

BACKGROUND: Patient selection is emerging as an important aspect of interventional treatment of acute ischemic stroke. The baseline CT scan and NIHSS can be performed very quickly to identify those patients who will have proximal arterial occlusions (PAOs) amenable to endovascular therapy. Hyperdense arteries (HDAs) identified on thin-slice reconstruction (0.625 mm slice) CT have been shown to predict PAOs on CT Angiography. We sought to determine whether the combination of clinical (NIHSS strata) and radiographic (standard 5mm slice non-contrast head CT) criteria could better identify ideal candidates for endovascular therapy. METHODS: We reviewed IMS I and II subjects who were treated with IV tPA for an anterior circulation stroke, and had a baseline standard head CT followed by a digital subtraction angiogram (DSA; n = 144 of the 161 patients in IMS I and II). Stroke severity (NIHSS 10-19, or ≥20), presence of a HDA on baseline CT (either in the ICA terminus or M1 branch of the MCA), and the location of arterial occlusions (either partial or complete) on DSA were determined. We calculated sensitivity, specificity and the positive predictive value (PPV) of stroke severity and a HDA for the presence of a PAO (ICA, M1 or M2 branches of MCA). RESULTS: 64 of 144 patients (44%) had a NIHSS ≥20. 74 of 144 patients (51%) had a HDA on CT (39 patients or 49% with NIHSS 10-19; 35 patients or 55% with NIHSS ≥20). After IV tPA, a PAO was seen on DSA in 105 (73%) of patients. DSA showed distal or no occlusion in 39 patients (13 of whom had a HDA on CT). The PPV of a HDA for a PAO was 82% (95%CI = 72-90%; sens = 58%, spec = 67%), whereas the PPV of NIHSS ≥20 for a PAO was 78% (95%CI = 66-87%; sens = 48%, spec = 64%). In patients with a HDA, consideration of stroke severity (NIHSS ≥20) only improved the PPV for a PAO to 86% (95%CI = 70-95%; sens = 60%, spec = 31%). In those with a HDA and a less severe stroke (NIHSS 10-19), PPV was 79% (95%CI = 63-91%; sens = 56%, spec = 68%). CONCLUSIONS: In patients with acute anterior circulation ischemic stroke, adding stroke severity does not appear to significantly improve the predictive value of a hyperdense artery on baseline standard CT for the presence of a proximal arterial occlusion after IV t-PA. Further study is needed to identify patients who are candidates for endovascular therapy.

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