Abstract WMP88: Temporal Trends in the Rates of Endovascular Treatment for Patients Presenting with Acute Ischemic Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Syed F Ali ◽  
Thabele M Leslie-Mazwi ◽  
Sanjeeva R Onteddu ◽  
Mehmet S Akdol ◽  
Adewumi D Amole ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Clinical Care ◽  
Temporal Trends ◽  
Standard Of Care ◽  
Patient Characteristics ◽  
Large Artery ◽  
Current Standard ◽  
Anterior Circulation ◽  
Stroke Registry

Introduction: Endovascular therapy is the current standard of care for eligible patients with acute ischemic stroke (AIS) due to large artery anterior circulation occlusion. All patients with moderate to severe symptoms and a treatable occlusion should be considered for EVT. We sought to evaluate temporal trends in the rates of EVT use at the two large academic stroke centers in the US. Methods: Using GWTG stroke registry data from MGH and UAMS, we analyzed 7,505 consecutive stroke admissions from 01/09 - 06/16. We evaluated the temporal trends in patient characteristics, clinical care and timeliness of care among the population of all patients and those treated within 6 or 12 hr from last known well (LKW). Results: Of the total 7,505 AIS patients, 3,722 (49%) presented within 12 hr of LKW and 2,716 (36%) within 6 hr. There were a total of 404 EVT performed at the two centers (334 ≤ 12 hr and 304 ≤ 6 hr). We observed a significant increase in the rates of EVTs performed over the past eight years with a near doubling of EVT and the sharpest rise in 2013-14 after the MR CLEAN results were presented (Figure 1). While patient characteristics remained largely unchanged, care got faster with significant decreases in time from door to CT, to tPA and to EVT. In addition, rates of drip and ship tPA cases increased from 26% to 39%. Conclusion: At two major academic stroke centers, rates of EVT increased sharply after high quality evidence supporting its use were presented. An ongoing national emphasis on improving door to tPA times appears to be working, and to be associated with improvements in EVT delivery as well. Further work is needed to improve prehospital triage and inhospital delays to increase access to rapid EVT.

Abstract WP32: Introducing STAR: A Multicenter International Collaborative Registry of Real-World Outcomes After Mechanical Thrombectomy for Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Ali M Alawieh ◽  
Shakeel Chowdhry ◽  
Italo Linfante ◽  
Jonathan Grossberg ◽  
Benjamin Gory ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Real World ◽  
Mechanical Thrombectomy ◽  
Standard Of Care ◽  
Outcome Data ◽  
Treatment Level ◽  
Current Standard ◽  
Anterior Circulation ◽  
Standard Of Care Treatment

Introduction: Mechanical thrombectomy (MT) for acute stroke is the current standard of care treatment. Level 1 evidence for efficacy of thrombectomy has been established in multiple randomized controlled trials on selective patient populations; however, the high effect size of MT had led multiple centers in the US and globally to expand their patient selection to include populations that were not studied in major trials. To provide ongoing data on MT outcomes in different patient populations from the real-world, we have initiated an international multicenter initiative, STAR (Stroke Thrombectomy and Aneurysm Registry). Methods: STAR is a multicenter and international platform to curate patient outcome data after MT for acute ischemic stroke at comprehensive stroke centers. STAR includes all patients who underwent MT for acute ischemic stroke irrespective of age, time from onset, ASPECT score, and NIHSS. Patients were curated from 01/2015 to date and is prospectively maintained. Patient charts are reviewed for demographics, baseline functioning, and admission deficits. Procedure notes are reviewed for technical variables and technical outcomes. Clinical outcomes were collected at 90-day follow-up by stroke neurologist. Results: A total of 24 centers globally have enrolled in STAR. By December 2018, the total number of enrolled and verified patients in STAR was 3,850 (mean age 69±14, 51% females). Anterior circulation strokes were treated in 89% of cases, average NIHSS on admission was 15.5±7, and 73% had pre-stroke mRS below 2. Around 51% of patients received IV-tPA. Mechanical thrombectomy was performed using aspiration (45%), stent retriever (28%), primary combined approach (24%) or intracranial stenting (3%). Successful recanalization was achieved in 84% of cases, the rate of favorable outcome (mRS 0-2) was 41%, and mortality was 25%. Complication rate was 6% and rate of symptomatic post-procedural hemorrhage was 6%. Conclusions: STAR represent a large real-world international registry for outcomes after MT, and constitutes a statistically robust platform to study real-world practice outcome in patient sub-populations that are under-represented in randomized trials. Link: https://medicine.musc.edu/departments/neurosurgery/star

Thrombectomy in acute ischemic stroke: estimations of increasing demands

2016 ◽  
Vol 9 (9) ◽  
pp. 830-833 ◽  
Author(s):  
Åsa Kuntze Söderqvist ◽  
Tommy Andersson ◽  
Niaz Ahmed ◽  
Nils Wahlgren ◽  
Magnus Kaijser
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Artery Occlusion ◽  
University Hospital ◽  
Stroke Severity ◽  
Large Artery ◽  
Anterior Circulation ◽  
Stroke Treatment ◽  
Stroke Registry ◽  
New Treatment

BackgroundNew recommendations for mechanical thrombectomy in acute ischemic stroke suggest that thrombectomy should be considered for eligible patients with a large artery occlusion in the anterior circulation within 6 hours of stroke onset. The resources are unevenly spread and, in order to be able to meet a potentially increased demand, we have estimated the future need for thrombectomy.MethodsThe new treatment recommendations are similar to those that have been in use at the Karolinska University Hospital since 2007. Using our local thrombectomy data (2009–2011), we calculated the proportion of thrombectomies performed at our hospital by level of stroke severity according to the National Institutes of Health Stroke Scale score (0–5, 6–11, 12–19, and 20–35). We then estimated the total number of potential thrombectomies expected in Sweden by extrapolating our treatment proportions to the rest of Sweden through the use of data from the Swedish National Stroke Registry.ResultsThe number of potential thrombectomies would have been more than five times higher (1268 estimated compared with 232 actually reported in the National Stroke Registry) if the new recommendations for thrombectomy in acute ischemic stroke had been implemented in 2013 (the year from which we had the most recent available data from the Swedish Stroke Registry).ConclusionsWhen the new recommendations are implemented broadly, there may be a substantial increase in demand for thrombectomies. Our study highlights the need for policymakers and healthcare professionals to prepare for the increasing demands for advanced endovascular stroke treatment.

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.

scholarly journals Endovascular Recanalization in Early Recurrent Ischemic Stroke: A Treatment Challenge

2020 ◽  
Vol 12 (Suppl. 1) ◽  
pp. 49-55
Author(s):  
Huong Bich Thi Nguyen ◽  
Thang Huy Nguyen
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Time Window ◽  
Recurrent Stroke ◽  
Reperfusion Therapy ◽  
Artery Occlusion ◽  
Large Artery ◽  
Limited Information ◽  
Anterior Circulation ◽  
Endovascular Recanalization

Reperfusion therapy is the most effective treatment for acute ischemic stroke. At present, many clinical studies have shown that mechanical thrombectomy is efficient and safe for acute ischemic stroke of large artery occlusion disease in the time window of 24 h. However, there is limited information on the safety and effectiveness of this technique in cases of recurrent ischemic stroke. We report a case of early recurrent stroke of the anterior circulation after a week of the first stroke. Imaging examinations showed that there existed occlusion of corresponding vessels and obvious ischemic penumbra. Symptoms of the patient were progressive worsening and medical treatment failed; therefore, the corresponding vessel was opened. The low perfusion status in brain tissue and clinical defect symptoms of the patients have improved a lot. In conclusion, thrombectomy for early recurrent ischemic stroke may be effective. Moreover, there may be a wider reperfusion time window for ischemic stroke patients.

Abstract WMP5: Predictors and Clinical Relevance of Hemorrhagic Transformation after Endovascular Therapy for Acute Ischemic Stroke: a Multicenter Retrospective Analysis of 1122 Patients

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Raul G Nogueira ◽  
Rishi Gupta ◽  
Tudor G Jovin ◽  
Elad I Levy ◽  
David Liebeskind ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
Atrial Fibrillation ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Retrospective Analysis ◽  
Endovascular Therapy ◽  
High Volume ◽  
Artery Occlusion ◽  
Large Artery ◽  
Anterior Circulation

Background and Purpose: Endovascular techniques are frequently employed to treat large artery occlusion in acute ischemic stroke (AIS). We sought to determine the predictors and clinical impact of intracranial hemorrhage (ICH) after endovascular therapy. Methods: Retrospective analysis of consecutive patients presenting to 13 high-volume stroke centers with AIS due to proximal occlusion in the anterior circulation who underwent endovascular treatment within 8 hours from symptom onset. Logistic regression was performed to determine the variables associated with ICH, hemorrhagic infarction (HI), and parenchymal hematomas (PH) as well as 90-day poor outcome (mRS≥3), and mortality. Results: A total of 1122 patients (mean age, 67±15 years; median NIHSS, 17 [IQR13-20]) were studied. Independent predictors for HI included diabetes mellitus (OR 2.27, 95%CI [1.58-3.26], p<0.0001), pre-procedure IV tPA (1.43[1.03-2.08], p<0.037), Merci thrombectomy (1.47[1.02-2.12], p<0.032), and longer time to puncture (1.001[1.00-1.002], p<0.026). Patients with atrial fibrillation (1.61[1.01-2.55], p<0.045) had a higher risk of parenchymal hematomas (PH) while the use of intra-arterial tPA (0.57[0.35-0.90], p<0.008) was associated with lower chances of PH. Both the presence of HI (2.23[1.53-3.25], p< 0.0001) and PH (6.24[3.06-12.75], p< 0.0001) were associated with poor functional outcomes; however, only PH was associated with higher mortality (3.53[2.19-5.68], p<0.0001). Conclusions: In AIS patients undergoing endovascular therapy, diabetes mellitus, longer time to treatment, and Merci thrombectomy appear to be associated with a higher risk for HI while atrial fibrillation appears to result in a higher risk for PH. While both HI and PH are associated with poor outcomes only PH is associated with higher mortality.

Abstract WP40: “Good” Angiographic Collateral Circulation Correlates With Lower Dwi Infarct Volumes In Acute Ischemic Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Esteban Cheng-Ching ◽  
Dolora Wisco ◽  
Shumei Man ◽  
Ferdinand Hui ◽  
Gabor Toth ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Collateral Circulation ◽  
Infarct Volume ◽  
Artery Occlusion ◽  
Grading System ◽  
Large Artery ◽  
Anterior Circulation ◽  
Vessel Occlusion

Background and purpose Large artery occlusion leads to ischemic stroke which volume is influenced by time from symptom onset. This effect is modulated by several factors, including the presence and degree of collateral circulation. We analyze the correlation between a standard angiographic collateral grading system and DWI infarct volumes. Methods We reviewed a prospectively collected retrospective database of ischemic stroke patients admitted between august of 2006 and december of 2011. We included patients with anterior circulation acute ischemic stroke presenting within 8 hours from symptom onset with large vessel occlusion, who underwent pre-treatment MRI and endovascular therapy. DWI infarct volumes were measured by region of interest. ASITN collateral grading system was used and grouped into “good collaterals” for grades 3 and 4, and “poor collaterals” for grades 0, 1 and 2. JMP statistical software was utilized. Results 152 patients (71 (46.7%) male, mean age: 68±15 years;) were included in the initial analysis. We identified 49 patients who had angiographic collateral circulation grading. Seven patients had ASITN collateral grade 0 with mean infarct volume of 27.6 cc, 25 had collateral grade of 1 with mean infarct volume of 27.9 cc, 10 had collateral grade of 2 with mean infarct volume of 23.4 cc, 5 had collateral grade of 3 with mean infarct volume of 6.3 cc, and 2 had collateral grade of 4 with mean infarct volume of 14.6 cc. Forty two patients had “poor collaterals” with a mean infarct volume of 26.8 cc. Seven patients had “good collaterals” with mean infarct volume of 8.7 cc. When comparing the infarct volumes between these two groups, the difference was statistically significant (p=0.017). Conclusions In anterior circulation acute ischemic stroke, “good” angiographic collateral circulation defined as ASITN grading system of 3 or 4, correlates with lower infarct volumes on presentation.

Abstract 205: Optimizing Prediction Scores for Poor Outcome After Intra-arterial Therapy for Anterior Circulation Acute Ischemic Stroke

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Amrou Sarraj ◽  
Andrew D Barreto ◽  
Karen Albright ◽  
Clark Sitton ◽  
Jeanie Choi ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Test Group ◽  
Scoring Systems ◽  
Roc Curves ◽  
Large Artery ◽  
Anterior Circulation ◽  
Significant Independent Predictor ◽  
Clinical Variables ◽  
Poor Outcome

Background: Intra-arterial therapy (IAT) is an approach to promote recanalization of large artery occlusions (LAO) in acute ischemic stroke (AIS) but is resource intensive. Previous studies evaluated different variables that affect clinical outcome after IAT. To better identify patients who have poor outcomes despite IAT, we compared the performance of previous predictive scoring systems that relied either on clinical or imaging variables in patients undergoing IAT. We then combined imaging and clinical variables to optimize a score that would better predict poor outcome after IAT for AIS. Methods: We studied consecutive AIS patients undergoing IAT at UT-Houston for LAO (MCA or ICA) from 01/03 to 05/11. We collected demographics and clinical variables and analyzed CT head scans using the ASPECTS scores by raters blinded to outcomes. Independent predictors of poor outcome (mRS 4–6) with p values ≤0.1 were evaluated as score variables using sensitivity analysis and logistic regression. Spearman’s correlation and ROC curves were used to evaluate the final score. Houston Intra-arterial Therapy 2 (HIAT2) score ranged from 0–10 with points for: age (≤59=0, 60–79=2, ≥80 years=4), Glucose (<150=0, ≥150=1), NIHSS (≤10=0), 11–20=1, ≥21=2), ASPECTS (8–10=0, ≤ 7=3). The score was created using 75% of the dataset (build group) and tested on the remaining 25% (test group). Previously published prediction scores (HIAT, THRIVE, ASPECTS) were compared against HIAT2. Results: Table 1 shows the clinical features for the 163 patients collected. Fig 1 shows the proportion of poor outcome based on HIAT-2. Patients with HIAT2 ≥ 5 were more likely to have a poor outcome at discharge (OR 6.43, 95% CI 2.75–15.02, p<.001). After adjusting for reperfusion (TICI≥2b, p=.7) and time from symptom onset to recanalization (p=.4), HIAT2 remained a significant independent predictor of poor outcome (OR 5.88, 95% CI 1.96–17.64, p=.02). Fig 2 shows the performance of HIAT2 against THRIVE, HIAT and ASPECTS as well as the validation of HIAT-2. Conclusions: Clinical prediction scores for patients undergoing IAT (HIAT, THRIVE) proved superior to the ASPECTS score. The HIAT2 score, which combines clinical and imaging variables, performed better than all previous scores in predicting the chance of poor outcome after IAT for anterior circulation LAO.

Abstract W P43: Clot Characteristics on Ct-angiography Predict Early Recanalization With Intravenous Tpa in Patients With Acute Ischemic Stroke

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Sachin Mishra ◽  
Jonathan Dykeman ◽  
Mohammed Almekhlafi ◽  
Muneer Eesa ◽  
Sung Il Sohn ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Regression Tree ◽  
Classification And Regression Tree ◽  
Residual Flow ◽  
Anterior Circulation ◽  
Stroke Registry ◽  
Regression Tree Analysis ◽  
Flow Through ◽  
Iv Tpa

Objective: We explore relationships amongst known and novel clot characteristics identified on CTA and early recanalization with IV tPA using classification and regression tree analysis (CART). Methods: Data is from patients presenting with acute ischemic stroke and proximal anterior circulation occlusions from the Calgary CTA database (2003-2012) and the Keimyung Stroke Registry (2005-2009). Patients who received IV t-PA followed by endovascular therapy were included. Clot location, clot length, residual flow through clot, ratio of contrast HU pre/post clot (cirHU) and distance of clot from M1 origin (for M1 MCA occlusions), were assessed on baseline CT-angio using OsiriX (Fig 1). Early recanalization (TICI 2a, 2b & 3) with IV t-PA was assessed on DSA first run. Results: We identified 228 patients (50.4% male, median age 69 yrs, median baseline NIHSS 17) who fulfilled inclusion criteria. Median symptom onset to IV t-PA time was 120 mins (IQR=70 mins) and median IV t-PA bolus to first angio run time was 70.5 mins (IQR=62 mins). Patients with residual flow within clot are five times more likely to recanalize than those without. Patients with residual flow within clot and a shorter clot length (≤15mm) were the most likely to recanalize(70.6%). Patients without residual flow with a carotid T/L occlusion rarely recanalized (1.7%). Patients without residual flow in M1 clots recanalized more if they were distal and had a cirHU < 2 (36.8%). (Fig 2). Inter-rater reliability for these clot characteristics was good to excellent. Conclusion: Clot characteristics on CTA could help physicians estimate early recanalization rates with IV tPA for proximal clots ranging from 0% to more than 80%.

Systematic evaluation of stroke thrombectomy in clinical practice: The German Stroke Registry Endovascular Treatment

2018 ◽  
Vol 14 (4) ◽  
pp. 372-380 ◽  
Author(s):  
Anna C Alegiani ◽  
Franziska Dorn ◽  
Moriz Herzberg ◽  
Frank A Wollenweber ◽  
Lars Kellert ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Practice ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Active Sites ◽  
Intravenous Thrombolysis ◽  
Standard Of Care ◽  
Systematic Evaluation ◽  
Stroke Treatment ◽  
Stroke Registry

Background Endovascular treatment has become standard of care for the treatment of acute ischemic stroke with large vessel occlusion. However, patients treated in clinical practice differ from the selected populations randomized in clinical trials. Aims The German Stroke Registry Endovascular Treatment (GSR-ET) aims at a systematic evaluation of outcome, safety, and process parameters of endovascular stroke treatment in standard of care in Germany. Methods The GSR-ET is an academic, independent, prospective, multicenter, observational registry study. Participating stroke centers from all over of Germany consecutively enroll patients transferred to the angiography suite with an intention to be treated with endovascular stroke treatment. Patients receive regular care. Data are collected as part of clinical routine. Baseline clinical and procedural information and clinical follow-up information after 90 days are recorded. Here, we present an analysis of baseline data of the first 1662 patients included in the GSR-ET. Results The registry was established in June 2015. By 31 December 2017, 1662 patients were enrolled in 23 active sites. Mean age was 72 ± 13 years, 50% were female, and median National Institutes of Health Stroke Scale on admission was 15 (IQR 10–19), 88% had anterior circulation occlusion. Median ASPECT score was 8 (IQR 7–10) prior to intervention. Fifty-nine percent of patients received intravenous thrombolysis prior to thrombectomy. Mean “onset-to-groin” time was 224 ± 176 min. Conclusions Baseline characteristics of stroke patients undergoing thrombectomy in clinical practice differ from those in the randomized trials. The GSR-ET will provide valuable insights into practices of endovascular treatment in routine care of acute ischemic stroke. (GSR-ET ClinicalTrials.gov Identifier: NCT03356392.)

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