Abstract WP40: Quick CT Perfusion Evaluation of Leptomeningeal Collateral Circulation: Single Cortical CBV-ROI

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Marta Rubiera ◽  
Alvaro Garcia-Tornell ◽  
Sandra Boned ◽  
Nicolas Romero ◽  
Pilar Coscojuela ◽  
...  
Keyword(s):  
Collateral Circulation ◽  
Ct Perfusion ◽  
Infarct Volume ◽  
Accurate Information ◽  
Outcome Predictor ◽  
Stroke Patients ◽  
Quick Method ◽  
Accurate Evaluation ◽  
The Mean ◽  
Contrast Ct

Good collateral circulation (CC) is a strong outcome predictor in acute stroke patients. CT angiography (CTA) is wide-world available but does not provide accurate information about parenchymal status. CT perfusion (CTP) is frequently used to determine ischemic core and tissue at risk. Our aim was to identify an easy and quick method to evaluate CC status by CTP. Methods: Consecutive ischemic stroke patients <8h from symptoms onset evaluated for reperfusion therapies were studied. Non-contrast CT, CTP and multiphase CTA were performed. Patients with confirmed M1-MCA or TICA occlusion on CTA were included. CC evaluation was determined by multiphase CTA (mCTA) according to the Calgary CC Scale and classified as poor (grades 0-2) or good (grades 3-5). In CTP maps, one single ipsi- and contralateral regions of interest (ROI) were defined in the MCA cortical territory (M4, M5, M6). We studied the association of absolute and relative to contralateral ROI-CTP values with CC degree determined by mCTA. Results: 33 patients were included, median NIHSS 17.5 (2-22). Twenty-five patients (75.8%) presented a M1 and 8 (24.2%) a TICA occlusion. On mCTA, 27 (81.8%) patients presented with a favourable CC status and 6 (18.2%) with poor CC. Mean ROI values in the ischemic MCA territory were: CBV 3.5±1.5 ml/100mg, CBF 46.9±29.3 ml/100mg/min, MTT 8.1±3.1 s, Tmax 23.2±4.4 s. In the contralateral non-ischemic MCA, the mean ROI values were: CBV 3.48±1.4, CBF 66.5±32.7, MTT 5.6±2.3, Tmax 20.4±4.8. Absolute and relative CBV-ROI data (relCBV= ischemic CBV value / contralateral CBV value) were the only values significantly associated with CC status on mCTA (good CC mean CBV: 3.8 ml/100g VS poor CC mean CBV: 1.9, p=0.006; good CC mean relCBV 1.1 vs poor CC mean relCBV 0.6, p=0.019). A ROC curve defined 2.5 ml/100mg as the better cut-off point of ROI-CBV that identified patients with good CC status (sensitivity 96%, specificity 84%, VPP 0.96, VPN 0.83). Patients with a ROI-CBV >2.5 presented lower median NIHSS after 24 hours (4 vs 18, p= 0.012) and smaller mean infarct volume on control CT (27.9 vs 88.3, p=0.021). Conclusion: A single cortical ROI-CBV allows an easy and quick accurate evaluation of collateral circulation in CTP. ROI-CBV>2.5 ml/100mg is related to good clinical and radiological outcomes.

scholarly journals Improving the Evaluation of Collateral Circulation by Multiphase Computed Tomography Angiography in Acute Stroke Patients Treated with Endovascular Reperfusion Therapies

2016 ◽  
Vol 5 (3-4) ◽  
pp. 209-217 ◽  
Author(s):  
Alvaro García-Tornel ◽  
Vanessa Carvalho ◽  
Sandra Boned ◽  
Alan Flores ◽  
David Rodríguez-Luna ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Acute Stroke ◽  
Computed Tomography Angiography ◽  
Collateral Circulation ◽  
Infarct Volume ◽  
National Institutes Of Health ◽  
Stroke Patients ◽  
Endovascular Thrombectomy ◽  
The Mean ◽  
Mean Time

Good collateral circulation (CC) is associated with favorable outcomes in acute stroke, but the best technique to evaluate collaterals is controversial. Single-phase computed tomography angiography (sCTA) is widely used but lacks temporal resolution. We aim to compare CC evaluation by sCTA and multiphase CTA (mCTA) as predictors of outcome in endovascular treated patients. Methods: Consecutive endovascular treated patients with M1 middle cerebral artery (MCA) or terminal intracranial carotid artery (TICA) occlusion confirmed by sCTA were included. Two more CTA acquisitions with 8- and 16-second delays were performed for mCTA. Endovascular thrombectomy was performed independently of the CC status according to a local protocol [Alberta Stroke Program Early CT score (ASPECTS) >6, modified Rankin scale (mRS) score <3]. CC on sCTA and mCTA were compared. Results: 108 patients were included. Their mean age was 69.6 ± 13 years and their median National Institutes of Health Stroke Scale (NIHSS) score was 17 (interquartile range 8). 79 (73.1%) had M1 MCA and 29 (26.9%) TICA occlusions. The mean time from symptom onset to CTA was 146.8 ± 96.5 min. On sCTA, 50.9% patients presented good CC vs. 57.5% on mCTA. Good CC status in both sCTA and mCTA had a lower 24-hour infarct volume (27.4 vs. 74.8 cm3 on sCTA, p = 0.04; 17.2 vs. 97.8 cm3 on mCTA, p < 0.01). However, only good CC on mCTA was associated with lower 24-hour (5 vs. 8.5, p = 0.04) and median discharge NIHSS (2 vs. 4.5, p = 0.04) scores and functional independency (mRS score <3) at 3 months (76.9 vs. 23.1%, p < 0.01). In a logistic regression model including age, NIHSS, ASPECTS and recanalization, only age (OR 0.96, 95% CI 0.93-0.99, p = 0.02) and good CC on mCTA (OR 5, 95% CI 1.99-12.6, p < 0.01) were independent predictors of functional outcome at 3 months. Conclusion: CC evaluation by mCTA is a better prognostic marker than CC evaluation by sCTA for clinical and functional endpoints in acute stroke patients treated with endovascular thrombectomy.

Nitroglycerin Is Not Associated with Improved Cerebral Perfusion in Acute Ischemic Stroke

2020 ◽  
pp. 1-9
Author(s):  
Mahesh Kate ◽  
Laura Gioia ◽  
Negar Asdaghi ◽  
Thomas Jeerakathil ◽  
Ashfaq Shuaib ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Cerebral Perfusion ◽  
Primary Outcome ◽  
Infarct Volume ◽  
Univariate Analysis ◽  
Primary Outcome Measure ◽  
Untreated Group ◽  
Stroke Patients ◽  
The Mean

ABSTRACT: Objective: The study was conducted to test the hypothesis that nitroglycerin (NTG) increases cerebral perfusion focally and globally in acute ischemic stroke patients, using serial perfusion-weighted imaging (PWI) magnetic resonance imaging measurements. Patients and methods: Thirty-five patients underwent PWI immediately before and 72 h after administration of a transdermal NTG patch or no treatment. Patients with baseline mean arterial pressure (MAP) > 100 mmHg (NTG group, n = 20) were treated with transdermal NTG (0.2 mg/h) for 72 h, without a nitrate-free interval. Patients with MAP ≤ 100 mmHg (untreated group, n = 15) were not treated. The primary outcome measure was absolute cerebral blood flow (CBF) in the hypoperfused region at 72 h. Results: The mean baseline absolute CBF in the hypoperfused region was similar in the NTG group (33.3 ± 10.2 ml/100 g/min) and untreated (32.7 ± 8.4 ml/100 g/min, p = 0.4) groups. The median (IQR) baseline infarct volume was 10.4 (2.5–49.3) ml in the NTG group and 32.6 (8.6–96.7) ml in the untreated group (p = 0.09). MAP change in the NTG group was 1.2 ± 12.6 and 8 ± 20.7 mmHg at 2 h and 72 h, respectively. Mean absolute CBF in the hypoperfused region at 72 h was similar in the NTG (29.9 ± 12 ml/100 g/min) and untreated groups (24.1 ± 10 ml/100 g/min, p = 0.8). The median infarct volume increased in untreated (11.8 (5.7–44.2) ml) than the NTG group (3.2 (0.5–16.5) ml; p = 0.033) on univariate analysis, however, there was no difference on regression analysis. Conclusion: NTG was not associated with improvement in cerebral perfusion in acute ischemic stroke patients.

Collateral Circulation Predicts the Size of the Infarct Core and the Proportion of Salvageable Penumbra in Hyperacute Ischemic Stroke Patients Treated with Intravenous Thrombolysis

2015 ◽  
Vol 40 (3-4) ◽  
pp. 182-190 ◽  
Author(s):  
Harri Rusanen ◽  
Jukka T. Saarinen ◽  
Niko Sillanpää
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Collateral Circulation ◽  
Cerebral Blood Volume ◽  
Treatment Time ◽  
Ct Perfusion ◽  
Mean Transit Time ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
The Impact

Background: We studied the impact of collateral circulation on CT perfusion (CTP) parametric maps and the amount of salvaged brain tissue, the imaging and clinical outcome at 24 h and at 3 months in a retrospective acute (<3 h) stroke cohort (105 patients) with anterior circulation thrombus treated with intravenous thrombolysis. Methods: Baseline clinical and imaging information were collected and groups with different collateral scores (CS) were compared. Binary logistic regression analyses using good CS (CS ≥2) as the dependent variable were calculated. Results: CTP Alberta Stroke Program Early CT Score (ASPECTS) was successfully assessed in 58 cases. Thirty patients displayed good CS. Poor CS were associated with more severe strokes according to National Institutes of Health Stroke Scale (NIHSS) at arrival (15 vs. 7, p = 0.005) and at 24 h (10 vs. 3, p = 0.003) after intravenous thrombolysis. Good CS were associated with a longer mean onset-to-treatment time (141 vs. 121 min, p = 0.009) and time to CTP (102 vs. 87 min, p = 0.047), better cerebral blood volume (CBV) ASPECTS (9 vs. 6, p < 0.001), better mean transit time (MTT) ASPECTS (6 vs. 3, p < 0.001), better noncontrast CT (NCCT) ASPECTS (10 vs. 8, p < 0.001) at arrival and with favorable clinical outcome at 3 months (modified Rankin Scale ≤2, p = 0.002). The fraction of penumbra that was salvageable at arrival and salvaged at 24 h was higher with better CS (p < 0.001 and p = 0.035, respectively). In multivariate analysis, time from the onset of symptoms to imaging (p = 0.037, OR 1.04 per minute, 95% CI 1.00-1.08) and CBV ASPECTS (p = 0.001, OR 2.11 per ASPECTS point, 95% CI 1.33-3.34) predicted good CS. In similar multivariable models, MTT ASPECTS (p = 0.04, OR 1.46 per ASPECTS point, 95% CI 1.02-2.10) and NCCT ASPECTS predicted good CS (p = 0.003, OR 4.38 per CT ASPECTS point, 95% CI 1.66-11.55) along with longer time from the onset of symptoms to imaging (p = 0.045, OR 1.03 per minute, 95% CI 1.00-1.06 and p = 0.02, OR 1.05 per minute, 95% CI 1.00-1.09, respectively). CBV ASPECTS had a larger area under the receiver operating characteristic curve for good CS (0.837) than NCCT ASPECTS (0.802) or MTT ASPECTS (0.752) at arrival. Conclusions: Favorable CBV ASPECTS, NCCT ASPECTS and MTT ASPECTS are associated with good CS along with more salvageable tissue and longer time from the onset of symptoms to imaging in ischemic stroke patients treated with intravenous thrombolysis.

scholarly journals Preliminary Application of a Quantitative Collateral Assessment Method in Acute Ischemic Stroke Patients With Endovascular Treatments: A Single-Center Study

2021 ◽  
Vol 12 ◽  
Author(s):  
Ruoyao Cao ◽  
Peng Qi ◽  
Yun Jiang ◽  
Shen Hu ◽  
Gengfan Ye ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Outcome ◽  
Acute Ischemic Stroke ◽  
Collateral Circulation ◽  
Ct Perfusion ◽  
Infarct Volume ◽  
Assessment Method ◽  
Outcome Evaluation ◽  
Analysis Time ◽  
Independent Predictive Factor

Objectives: To develop an efficient and quantitative assessment of collateral circulation on time maximum intensity projection CT angiography (tMIP CTA) in patients with acute ischemic stroke (AIS).Methods: Eighty-one AIS patients who underwent one-stop CTA-CT perfusion (CTP) from February 2016 to October 2020 were retrospectively reviewed. Single-phase CTA (sCTA) and tMIP CTA were developed from CTP data. Ischemic core (IC) volume, ischemic penumbra volume, and mismatch ratio were calculated. The Tan scale was used for the qualitative evaluation of collateral based on sCTA and tMIP CTA. Quantitative collateral circulation (CCq) parameters were calculated semi-automatically with software by the ratio of the vascular volume (V) on both hemispheres, including tMIP CTA VCCq and sCTA VCCq. Spearman correlation analysis was used to analyze the correlation of collateral-related parameters with final infarct volume (FIV). ROC and multivariable regression analysis were calculated to compare the significance of the above parameters in clinical outcome evaluation. The analysis time of the observers was also compared.Results: tMIP CTA VCCq (r = 0.61, p &lt; 0.01), IC volume (r = 0.66, p &lt; 0.01), Tan score on tMIP CTA (r = 0.52, p &lt; 0.01) and mismatch ratio (r = 0.60, p &lt; 0.01) showed moderate negative correlations with FIV. tMIP CTA VCCq showed the best prognostic value for clinical outcome (AUC = 0.93, p &lt; 0.001), and was an independent predictive factor of clinical outcome (OR = 0.14, p = 0.009). There was no difference in analysis time of tMIP CTA VCCq among observers (p = 0.079).Conclusion: The quantitative evaluation of collateral circulation on tMIP CTA is associated with clinical outcomes in AIS patients with endovascular treatments.

Abstract 38: Brain CT Perfusion is Superior to Non-contrast CT Aspects in the Evaluation of Hyperacute Infarct Volume

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jelle Demeestere ◽  
Carlos Garcia-Esperon ◽  
Pablo Garcia-Bermejo ◽  
Fouke Ombelet ◽  
Patrick McElduff ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Ct Perfusion ◽  
Infarct Volume ◽  
Lesion Volume ◽  
Infarct Core ◽  
Anterior Circulation ◽  
C Statistic ◽  
Contrast Ct ◽  
Core Volume

Objective: To compare the predictive capacity to detect established infarct in acute anterior circulation stroke between the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) on non-contrast computed tomography (CT) and CT perfusion. Methods: Fifty-nine acute anterior circulation ischemic stroke patients received brain non-contrast CT, CT perfusion and hyperacute magnetic resonance imaging (MRI) within 100 minutes from CT imaging. ASPECTS scores were calculated by 4 independent vascular neurologists, blinded from CT perfusion and MRI data. CT perfusion infarct core volumes were calculated by MIStar software. The accuracy of commonly used ASPECTS cut-off scores and a CT perfusion core volume of ≥ 70 mL to detect a hyperacute MRI diffusion lesion of ≥ 70 ml was evaluated. Results: Median ASPECTS score was 9 (IQR 7-10). Median CT perfusion core volume was 22 ml (IQR 10.4-71.9). Median MRI diffusion lesion volume was 24,5 ml (IQR 10-63.9). ASPECTS score of < 6 had a sensitivity of 0.37, specificity of 0.95 and c-statistic of 0.66 to predict an acute MRI lesion ≥ 70 ml. In comparison, a CT perfusion core lesion of ≥ 70 ml had a sensitivity of 0.76, specificity of 0.98 and c-statistic of 0.92. The CT perfusion core lesion covered a median of 100% of the acute MRI lesion volume (IQR 86-100%). Conclusions: CT perfusion is superior to ASPECTS to predict hyperacute MRI lesion volume in ischemic stroke.

Abstract 33: Qualitative Description of Ischemic Stroke Appearance on Low-Field, Point-Of-Care Magnetic Resonance Imaging

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Matthew Yuen ◽  
Mercy Mazurek ◽  
Bradley Cahn ◽  
Anjali Prabhat ◽  
Samantha By ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Signal Intensity ◽  
Infarct Volume ◽  
Point Of Care ◽  
Qualitative Description ◽  
Stroke Severity ◽  
Slice Thickness ◽  
Stroke Patients ◽  
Low Field ◽  
The Mean

Background and Aims: Advances in low-field MRI have enabled image acquisition at the point-of-care (POC). We aim to characterize ischemic lesions in low-field, POC MRI and assess its relationship with stroke severity in ischemic stroke patients. Methods: We performed POC MRI exams on ischemic stroke patients. T2-weighted (T2W), fluid-attenuated inversion recovery (FLAIR), and diffusion-weighted imaging (DWI) exams were acquired with a 64mT, portable bedside MRI system. Three raters computed signal intensity ratios (SIR) for each sequence. For every slice showing an infarct, an SIR was generated by dividing the mean signal intensity of the lesion by the mean signal intensity of the contralateral hemisphere. Infarct volumes were obtained by multiplying the lesion area of each slice by the slice thickness (5mm) and summing the cross-sectional areas. Volumes were correlated with National Institutes of Health Stroke Scale (NIHSS) scores at the time of scan. Results: We studied 18 ischemic stroke patients (50% women; ages 30-95 years). Two patients were studied at two and three serial timepoints, respectively. POC exams were obtained 2.7 ± 2.2 days after symptom onset. A total of 18 T2W, 17 FLAIR, and 18 DWI exams were obtained. Three exams (1 T2W; 1 FLAIR; 1 DWI) were excluded due to motion degradation. High field MRI exams (19 ± 16 hours from POC exams) demonstrated ischemic infarcts in 15 of the 18 patients. All POC T2W and FLAIR exams revealed infarcts in these patients, and 14 of the 17 DWI exams showed infarcts. Ischemic infarcts were seen as hyperintense lesions (SIR: T2W = 1.19 ± 0.10, FLAIR = 1.15 ± 0.08, DWI = 1.36 ± 0.17). Infarct volume significantly correlated with NIHSS scores (T2W: r = 0.71, p < 0.01; FLAIR: r = 0.65, p < 0.05; DWI: r = 0.65, p < 0.05). Conclusions: These preliminary data suggest that low-field, POC MRI may be useful in the clinical evaluation of ischemic stroke. Further work in larger cohorts is needed to elucidate the appearance of infarction on low-field imaging.

scholarly journals CT perfusion in hyper-acute ischemic stroke: the acid test for COVID-19 fear

2021 ◽  
Author(s):  
Giovanni Furlanis ◽  
Miloš Ajčević ◽  
Ilario Scali ◽  
Alex Buoite Stella ◽  
Sasha Olivo ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Clinical Presentation ◽  
Ct Perfusion ◽  
Infarct Volume ◽  
Sudden Onset ◽  
Stroke Patients ◽  
Severe Clinical Presentation ◽  
Acid Test ◽  
Core Volume

Abstract Purpose The fear of COVID-19 infection may discourage patients from going to the hospital even in case of sudden onset of disabling symptoms. There is growing evidence of the reduction of stroke admissions and higher prevalence of severe clinical presentation. Yet, no studies have investigated the perfusion pattern of acute strokes admitted during the lockdown. We aimed to evaluate the effects of the COVID-19 pandemic on hyper-acute stroke CT perfusion (CTP) pattern during the first months of the pandemic in Italy. Methods In this retrospective observational study, we analyzed CTP images and clinical data of ischemic stroke patients admitted between 9 March and 2 June 2020 that underwent CTP (n = 30), to compare ischemic volumes and clinical features with stroke patients admitted during the same period in 2019 (n = 51). In particular, CTP images were processed to calculate total hypoperfused volumes, core volumes, and mismatch. The final infarct volumes were calculated on follow-up CT. Results Significantly higher total CTP hypoperfused volume (83.3 vs 18.5 ml, p = 0.003), core volume (27.8 vs 1.0 ml, p < 0.001), and unfavorable mismatch (0.51 vs 0.91, p < 0.001) were found during the COVID-19 period compared to no-COVID-19 one. The more unfavorable perfusion pattern at admission resulted in higher infarct volume on follow-up CT during COVID-19 (35.5 vs 3.0 ml, p < 0.001). During lockdown, a reduction of stroke admissions (− 37%) and a higher prevalence of severe clinical presentation (NIHSS ≥ 10; 53% vs 36%, p = 0.029) were observed. Conclusion The results of CTP analysis provided a better insight in the higher prevalence of major severity stroke patients during the COVID-19 period.

Abstract WP71: Intravenous Thrombolysis in Stroke-mimics: Is There a Relationship With Door-to-needle Time?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Elisa Campos-Costa ◽  
Carmen Labandeira-Guerra ◽  
Cristina Martínez-Reglero ◽  
Sandra Boned ◽  
Maria Muchada ◽  
...  
Keyword(s):  
Clinical Characteristics ◽  
Ct Perfusion ◽  
Intravenous Thrombolysis ◽  
Treatment Decision ◽  
Final Diagnosis ◽  
Neurological Deficits ◽  
Stroke Patients ◽  
Stroke Mimics ◽  
Contrast Ct ◽  
Iv Tpa

Introduction: Several non-vascular conditions may mimic the sudden neurological deficits of stroke (stroke mimics, SM). In Stroke Code, time to treatment is crucial, but the efforts to increase the benefits of iv-tPA may lead to inadvertent treatment of SM. We aim to determine the relationship between door-to-needle (DTN) time and SM treatment. Methods: Retrospective analysis of all acute stroke patients treated with iv-tPA included in an institutional prospective database. SM were identified during follow-up and their clinical characteristics compared with the confirmed stroke patients in the same time-period. Results: During a 3-year period, 332 thrombolysed patients were included. Twenty-two were SM (6.6%, 95%CI:4.0%-9.3%), with median age of 58 years (range 35-87), 54.5% were men, median NIHSS=10 (range 3-30). Sudden (81.8%) neurological deficits were motor in 11 patients (52.2%), altered speech in 10 (47.6%) and sensitive in 7 (33.3%). Baseline clinical characteristics (including age, sex, vascular risk factors and initial NIHSS) were similar between stroke and SM groups. Multimodal imaging was used for treatment decision in 95.5% of SM (CT-perfusion 10 patients, CT-angiography 9, MRI 1 and only 1 patient received just non-contrast CT) vs 74.1% of confirmed strokes (p=0.014). Four SM patients presented with neuroimaging abnormalities. DTN of SM was similar to those of strokes (35.5 VS. 40minutes, p=0.6). Despite a progressive decrease in median DTN time (year 1: 47min vs year 3: 36min; p=0.02) the rate of SM treated with tPA did not increase (year 1: 5.4% vs 9% in year 3; p=0.1). No intracranial haemorrhage or other complications were recorded in any SM patient. At discharge, 86.4% of SM presented a modified Rankin Scale 0-1. The most frequent final diagnosis were: migraine (31.8%), functional symptoms (27.3%) and seizures (27.3%). Conclusions: Despite multimodal neuroimaging, stat differentiation between SM and stroke is still difficult. Reduction of DTN times may not necessarily increase the number of SM thrombolysed. Nevertheless, iv-tPA revealed to be safe in SM and should not be delayed in case of doubt.

Abstract T P44: Relative Cerebral Blood Volume as a Marker of Durable Tissue-at-risk Viability in Hyperacute Ischemic Stroke

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Ana I. Calleja ◽  
Elisa Cortijo ◽  
Pablo García-Bermejo ◽  
Mario Martinez-Gáldamez ◽  
Santiago Pérez-Fernández ◽  
...  
Keyword(s):  
At Risk ◽  
Ischemic Stroke ◽  
Blood Volume ◽  
Collateral Circulation ◽  
Cerebral Blood Volume ◽  
Infarct Volume ◽  
Intravenous Thrombolysis ◽  
Stroke Patients ◽  
Long Term Outcome ◽  
Perfusion Computed Tomography

Background: Selection of best responders to endovascular reperfusion could be aided by predicting the expected duration of tissue-at-risk viability, which may be dependant on collateral circulation status. We aimed to identify the best predictor of good collateral circulation among perfusion computed tomography (PCT) parameters in middle cerebral artery (MCA) ischemic stroke, and to analyze how early MCA response to intravenous thrombolysis and PCT-derived markers of good collaterals interact to determine stroke outcome. Methods: We prospectively studied acute MCA ischemic stroke patients treated with intravenous thrombolysis who underwent PCT prior to treatment showing a target-mismatch profile. Collateral status was assessed using a PCT source-images based score. PCT maps were quantitatively analyzed. Cerebral blood volume (CBV), cerebral blood flow (CBF) and Tmax were calculated within the hypoperfused volume and in the equivalent region of unaffected hemisphere. Occluded MCAs were monitored by transcranial Duplex to assess early recanalization. Main outcome variables were final infarct volume and modified Rankin score at day 90. Results: One hundred MCA ischemic stroke patients imaged by PCT received intravenous thrombolysis, and 68 met all inclusion criteria. A relative CBV > 0.93 emerged as the most robust predictor of good collaterals [OR 12.6 (95% CI 2.9-55.9), p=0.001]. Early MCA recanalization was strongly associated with better long-term outcome and lower infarct volume in patients with rCBV <0.93, but not in patients with high rCBV. None of the patients with rCBV < 0.93 achieved good outcome in absence of early recanalization. Conclusion: rCBV was the strongest marker of collateral status and may help predict the duration of tissue-at-risk viability in hyperacute MCA ischemic stroke

Endovascular treatment beyond 24 hours from the onset of acute ischemic stroke: the Italian Registry of Endovascular Thrombectomy in Acute Stroke (IRETAS)

2021 ◽  
pp. neurintsurg-2021-018045
Author(s):  
Ilaria Casetta ◽  
Enrico Fainardi ◽  
Giovanni Pracucci ◽  
Valentina Saia ◽  
Stefano Vallone ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Ct Perfusion ◽  
Case Fatality ◽  
Functional Independence ◽  
Primary Outcome Measure ◽  
Stroke Patients ◽  
Infarct Core ◽  
Endovascular Thrombectomy ◽  
Symptomatic Intracranial Hemorrhage ◽  
Contrast Ct

BackgroundClinical trials and observational studies have demonstrated the benefit of thrombectomy up to 16 or 24 hours after the patient was last known to be well. This study aimed to evaluate the outcome of stroke patients treated beyond 24 hours from onset.MethodsWe analyzed the outcome of 34 stroke patients (mean age 70.7±12.3 years; median National Institutes of Health Stroke Scale (NIHSS) score 13) treated with endovascular thrombectomy beyond 24 hours from onset who were recruited in the Italian Registry of Endovascular Thrombectomy in Acute Stroke. Selection criteria for patients were: pre-stroke modified Rankin scale (mRS) score of ≤2, non-contrast CT Alberta Stroke Program Early CT score of ≥6, good collaterals on single phase CT angiography (CTA) or multiphase CTA, and CT perfusion mismatch with an infarct core size ≤50% of the total hypoperfusion extent or involving less than one-third of the extent of the middle cerebral artery territory evaluated by visual inspection. The primary outcome measure was functional independence assessed by the mRS at 90 days after onset. Safety outcomes were 90 day mortality and the occurrence of symptomatic intracranial hemorrhage (sICH).ResultsSuccessful recanalization (Thrombolysis in Cerebral Infarction score of 2b or 3) was present in 76.5% of patients. Three month functional independence (mRS score 0–2) was observed in 41.1% of patients. The case fatality rate was 26.5%. and the incidence of sICH was 8.8%.ConclusionsThese findings suggest that, in a real world setting, very late endovascular therapy is feasible in appropriately selected patients.

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