Abstract 172: Bridging Therapy versus Intravenous Thrombolysis in Minor Stroke With Large Vessel Occlusion. A French Multicentric Observational Study (MINOR-STROKE)

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Pierre Seners ◽  
Claire Perrin ◽  
Guillaume Turc ◽  
. on behalf of the Minor-Stroke Collaborators
Keyword(s):  
Propensity Score ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Minor Stroke ◽  
Large Vessel Occlusion ◽  
Bridging Therapy ◽  
Vessel Occlusion ◽  
Potential Harm ◽  
Stroke Units ◽  
Excellent Outcome

Introduction: Whether bridging therapy (endovascular therapy [EVT] plus intravenous thrombolysis [IVT]) is superior to IVT alone in minor strokes with large vessel occlusion (LVO) is unknown. Methods: MINOR-STROKE was a multicentric retrospective cohort collecting data of IVT-treated minor strokes (NIHSS≤5) with LVO (ICA, M1 or M2; with central reading) treated with or without additional EVT in 45 French stroke units. Patients immediately intended for additional EVT -including those who eventually did not receive EVT- were analyzed in the bridging group, whereas patients initially intended for IVT alone -including those who eventually received rescue EVT- were analyzed in the IVT group. Propensity-score (inverse probability of treatment weighting) was used to reduce baseline between-groups differences. The primary outcome was excellent outcome defined as mRS 0-1 at 3 month. Results: Overall, 965 patients were included (237 and 728 in the bridging therapy and IVT groups, respectively). The distribution of all baseline clinical and radiological variables across the 2 groups were similar following propensity-score weighting. Compared with IVT alone, bridging therapy was not associated with better excellent outcome (OR=0.99; 95%CI 0.79-1.24; P =0.95), but was associated with higher risks of symptomatic intracranial haemorrhage (OR=2.39; 95%CI 1.51-3.80; P <0.001). However, occlusion site was a strong modifier of the effect of bridging therapy on excellent outcome (P interaction <0.0001), bridging therapy seeming beneficial in isolated ICA (OR=2.75; 95%CI 1.23 6.13; P =0.01) and proximal M1±ICA (OR=3.63; 95%CI 1.94-6.79; P <0.0001), neutral for distal M1±ICA (OR=0.96; 95%CI 0.63-1.48; P =0.87) but deleterious for M2±ICA (OR=0.54; 95%CI 0.38-0.75; P <0.001) occlusions. Bridging therapy was only associated with sICH in patients with M2 occlusions (OR=4.73; 95%CI 2.35-9.49; P <0.0001). Conclusion: Overall, we observed similar outcomes with bridging therapy or IVT alone in minor strokes with LVO. However, our data suggest benefit of bridging therapy in patients with ICA or proximal M1 occlusion and potential harm through sICH in patients with M2 occlusion. Randomized trials are strongly commended to confirm these results.

Abstract 101: Predictors of Early Neurological Deterioration in Minor Strokes With Large Vessel Occlusion Treated With Intravenous Thrombolysis. A French Multicentric Observational Study (MINOR-STROKE)

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Pierre Seners ◽  
Claire Perrin ◽  
Guillaume Turc
Keyword(s):  
Basilar Artery ◽  
Multivariable Analysis ◽  
Intravenous Thrombolysis ◽  
Neurological Deterioration ◽  
Large Vessel ◽  
Minor Stroke ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Early Neurological Deterioration ◽  
Proximal Occlusion

Introduction: Whether thrombectomy added on intravenous thrombolysis (IVT), as compared to IVT alone, is beneficial in minor strokes with large vessel occlusion (LVO) is unknown. To identify predictors of early neurological deterioration (END) following IVT alone may help to select the best candidates for additional thrombectomy. Methods: MINOR-STROKE was a multicentric retrospective registry collecting data of IVT-treated minor strokes (NIHSS≤5) with LVO (internal carotid artery [ICA], M1, M2 or basilar artery; with central reading) treated with or without additional thrombectomy in 45 French stroke units. The patients initially intended for IVT alone, including those who eventually received thrombectomy due to END, were included in the present analysis. END was defined as a ≥4 points on NIHSS within 24hrs following admission. Thrombus length was measured centrally either on T2*-MRI, CT (hyperdense middle cerebral artery) or CT-angiography. Results: Overall, 799 patients were included: mean age 69 years, median NIHSS 3, occlusion located in ICA±M1/M2, proximal M1, distal M1, M2, or basilar artery in 20%, 7%, 19%, 50% and 4% of patients, respectively. Thrombus was visible in 78% of patients (median length 9mm, IQR 6-12mm). END occurred in 15% of patients and was associated with poor 3-month functional outcome (mRS>2: 55% vs. 12% of patients with and without END, respectively). Only 15% of ENDs were due to intracranial haemorrhage. In multivariable analysis, a more proximal occlusion site (M2 [reference], distal M1: OR 2.1 [IC95% 1.1-4.1], proximal M1: OR 3.8 [1.6-9.1], ICA±M1/M2: OR 5.0 [2.6-9.6], basilar artery: OR 4.9 [1.1-4.1]; P <0.001) and a longer thrombus (<6mm [reference], [6-9mm[: OR 1.3 [IC95% 0.6-2.9], [9-12mm[: OR 1.8 [0.8-3.9] and ≥12mm: OR 2.7 [1.3-5.6]; P =0.036) were independently associated with END. END occurred in 33%, 19%, 14%, 7% and 27% of patients with ICA±M1/M2, M1 proximal, M1 distal, M2 and basilar artery, respectively, and in 8%, 10%, 14% et 23% of patients with thrombus length of <6, [6-9[, [9-12[ and ≥12mm, respectively. Conclusion: Our study suggests that thrombus location and length are strong predictors of END in minor strokes with LVO. This may help to select the best candidates for additional endovascular therapy.

scholarly journals What Is the “Optimal” Target Mismatch Criteria for Acute Ischemic Stroke?

2021 ◽  
Vol 11 ◽  
Author(s):  
Chushuang Chen ◽  
Mark W. Parsons ◽  
Christopher R. Levi ◽  
Neil J. Spratt ◽  
Longting Lin ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Perfusion Imaging ◽  
Delay Time ◽  
Intravenous Thrombolysis ◽  
Population Characteristics ◽  
Large Vessel ◽  
Perfusion Deficit ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Excellent Outcome

We aimed to compare Perfusion Imaging Mismatch (PIM) and Clinical Core Mismatch (CCM) criteria in ischemic stroke patients to identify the effect of these criteria on selected patient population characteristics and clinical outcomes. Patients from the INternational Stroke Perfusion Imaging REgistry (INSPIRE) who received reperfusion therapy, had pre-treatment multimodal CT, 24-h imaging, and 3 month outcomes were analyzed. Patients were divided into 3 cohorts: endovascular thrombectomy (EVT), intravenous thrombolysis alone with large vessel occlusion (IVT-LVO), and intravenous thrombolysis alone without LVO (IVT-nonLVO). Patients were classified using 6 separate mismatch criteria: PIM-using 3 different measures to define the perfusion deficit (Delay Time, Tmax, or Mean Transit Time); or CCM-mismatch between age-adjusted National Institutes of Health Stroke Scale and CT Perfusion core, defined as relative cerebral blood flow &lt;30% within the perfusion deficit defined in three ways (as above). We assessed the eligibility rate for each mismatch criterion and its ability to identify patients likely to respond to treatment. There were 994 patients eligible for this study. PIM with delay time (PIM-DT) had the highest inclusion rate for both EVT (82.7%) and IVT-LVO (79.5%) cohorts. In PIM positive patients who received EVT, recanalization was strongly associated with achieving an excellent outcome at 90-days (e.g., PIM-DT: mRS 0-1, adjusted OR 4.27, P = 0.005), whereas there was no such association between reperfusion and an excellent outcome with any of the CCM criteria (all p &gt; 0.05). Notably, in IVT-LVO cohort, 58.2% of the PIM-DT positive patients achieved an excellent outcome compared with 31.0% in non-mismatch patients following successful recanalization (P = 0.006).Conclusion: PIM-DT was the optimal mismatch criterion in large vessel occlusion patients, combining a high eligibility rate with better clinical response to reperfusion. No mismatch criterion was useful to identify patients who are most likely response to reperfusion in non-large vessel occlusion patients.

scholarly journals Intended Bridging Therapy or Intravenous Thrombolysis Alone in Minor Stroke With Basilar Artery Occlusion

Stroke ◽  
2021 ◽  
Author(s):  
Pierre Seners ◽  
Cyril Dargazanli ◽  
Michel Piotin ◽  
Denis Sablot ◽  
Serge Bracard ◽  
...  
Keyword(s):  
Propensity Score ◽  
Scale Score ◽  
Basilar Artery ◽  
Intravenous Thrombolysis ◽  
Artery Occlusion ◽  
Basilar Artery Occlusion ◽  
Minor Stroke ◽  
Bridging Therapy ◽  
Excellent Outcome ◽  
Propensity Score Weighting

Background and Purpose: Whether bridging therapy (intravenous thrombolysis [IVT] followed by mechanical thrombectomy) is superior to IVT alone in minor stroke with basilar artery occlusion remains uncertain. Methods: Multicentric retrospective observational study of consecutive minor stroke patients (National Institutes of Health Stroke Scale score ≤5) with basilar artery occlusion intended for IVT alone or bridging therapy. Propensity-score weighting was used to reduce baseline between-groups differences, and residual imbalance was addressed through adjusted logistic regression, with excellent outcome (3-month modified Rankin Scale score 0–1) as the dependent variable. Results: Fifty-seven patients were included (28 and 29 in the bridging therapy and IVT alone groups, respectively). Following propensity-score weighting, the distribution of baseline clinical and radiological variables was similar across the 2 patient groups, except age, posterior circulation Alberta Stroke Program Early CT Score, history of hypertension and smoking, and onset-to-IVT time. Compared with IVT alone, bridging therapy was associated with excellent outcome (adjusted odds ratio=3.37 [95% CI, 1.13–10.03]; P =0.03). No patient experienced symptomatic intracranial hemorrhage. Conclusions: Our results suggest that bridging therapy may be superior to IVT alone in minor stroke with basilar artery occlusion.

Abstract P345: Perfusion-Guided Bridging Therapy in Strokes With Unknown Time of Onset and Large Vessel Occlusion

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Jose Bernardo Escribano Paredes ◽  
Julian Klug ◽  
Elisabeth Dirren ◽  
Nicolae Sanda ◽  
Maria Vargas ◽  
...  
Keyword(s):  
Intravenous Thrombolysis ◽  
Stroke Onset ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Bridging Therapy ◽  
Vessel Occlusion ◽  
Intracerebral Bleeding ◽  
Interhospital Transfer ◽  
Symptom Recognition ◽  
Increased Risk

Introduction: Endovascular treatment (EVT) is the therapy of choice, in patients with unknown stroke onset (unwitnessed and wake-up strokes) and large vessel occlusion (LVO) with a favorable perfusion pattern. Whether bridging therapy (intravenous thrombolysis (IVT) and EVT) is superior to EVT alone remains unknown. Material and Methods: We retrospectively included all patients admitted to the Geneva University Hospital from 01.2016 to 06.2020 with i) stroke of unknown onset, due to ii) anterior circulation occlusion, with iii) favorable CT perfusion pattern based on the DEFUSE criteria (ischemic core volume< 70ml; mismatch ratio >= 1.8 and mismatch volume >= 15ml), and iv) treated < 4.5 hours after symptom recognition. As a standard of care, the patients fulfilling these inclusion criteria were treated with EVT and IVT or EVT alone when IVT was contraindicated. Outcome measures were any intracerebral bleeding (symptomatic or asymptomatic), mortality and favorable outcome (mRS 0-1) at three months. Results: 32 patients were included (17 treated with EVT alone and 15 with EVT and IVT). Mean age was 69±18 yo. Median NIHSS was 16 (IQR 12-20) and median time from symptom recognition to treatment was 184 (146-226) minutes. Median hypoperfused tissue volume (Tmax > 6s) was 119 ml (80-151) and infarcted core (CBF ratio <30%) 8 ml (0-27). After propensity score weighting, bridging therapy was not associated with an increased risk of intracerebral bleeding (p=0.72) or mortality (p=0.55). The proportion of favorable outcomes at three months was similar between treatment groups (p=0.78). Conclusion: These results suggest that IVT before EVT is a safe therapeutic option in patients with unknown stroke onset selected on perfusion imaging and treated <4.5 hours after symptom recognition. Early administration of IVT may be particularly relevant before interhospital transfer to a comprehensive stroke center for EVT.

Impact of Strategy on Clinical Outcome in Large Vessel Occlusion Stroke Successfully Reperfused: ETIS Registry Results

Stroke ◽  
2021 ◽  
Author(s):  
Marian Douarinou ◽  
Benjamin Gory ◽  
Arturo Consoli ◽  
Bertrand Lapergue ◽  
Maeva Kyheng ◽  
...  
Keyword(s):  
Odds Ratio ◽  
Therapy Group ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Favorable Outcome ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Bridging Therapy ◽  
Anterior Circulation ◽  
Vessel Occlusion

Background and Purpose: Approximately half of the patients with acute ischemic stroke due to anterior circulation large vessel occlusion do not achieve functional independence despite successful reperfusion. We aimed to determine influence of reperfusion strategy (bridging therapy, intravenous thrombolysis alone, or mechanical thrombectomy alone) on clinical outcomes in this population. Methods: From ongoing, prospective, multicenter, observational Endovascular Treatment in Ischemic Stroke registry in France, all patients with anterior circulation large vessel occlusion who achieved successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b-3) following reperfusion therapy were included. Primary end point was favorable outcome, defined as 90-day modified Rankin Scale score ≤2. Patient groups were compared using those treated with bridging therapy as reference. Differences in baseline characteristics were reduced after propensity score-matching, with a maximum absolute standardized difference of 14% for occlusion site. Results: Among 1872 patients included, 970 (51.8%) received bridging therapy, 128 (6.8%) received intravenous thrombolysis alone, and the remaining 774 (41.4%) received MT alone. The rate of favorable outcome was comparable between groups. Excellent outcome (90-day modified Rankin Scale score 0–1) was achieved more frequently in the bridging therapy group compared with the MT alone (odds ratio after propensity score-matching, 0.70 [95% CI, 0.50–0.96]). Regarding safety outcomes, hemorrhagic complications were similar between the groups, but 90-day mortality was significantly higher in the MT alone group compared with the bridging therapy group (odds ratio, 1.60 [95% CI, 1.09–2.37]). Conclusions: This real-world observational study of patients with anterior circulation large vessel occlusion demonstrated a similar rate of favorable outcome following successful reperfusion with different therapeutic strategies. However, our results suggest that bridging therapy compared with MT alone is significantly associated with excellent clinical outcome and lower mortality. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03776877.

Bridging Therapy or IV Thrombolysis in Minor Stroke with Large Vessel Occlusion

2020 ◽  
Vol 88 (1) ◽  
pp. 160-169 ◽  
Author(s):  
Pierre Seners ◽  
Claire Perrin ◽  
Bertrand Lapergue ◽  
Hilde Henon ◽  
Séverine Debiais ◽  
...  
Keyword(s):  
Large Vessel ◽  
Minor Stroke ◽  
Large Vessel Occlusion ◽  
Bridging Therapy ◽  
Vessel Occlusion

Abstract WMP11: Safety and Efficacy of Mechanical Thrombectomy in Patients With Minor Stroke Due to Large Vessel Occlusion- Insights From the STAR Registry

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Sami Al Kasab ◽  
Eyad Almallouhi ◽  
Ali Alawieh ◽  
Reda M Chalhoub ◽  
Marios Psychogios ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Severe Symptom ◽  
Large Vessel ◽  
Minor Stroke ◽  
Complication Rates ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Safety And Efficacy ◽  
Excellent Outcome ◽  
Symptom Group

Introduction: Mechanical thrombectomy (MT) is the current standard of care treatment for patients presenting with severe symptoms due to large vessel occlusion (LVO); approximately 30% of patients with LVO however present with mild symptoms (NIHSS < 6). The safety and efficacy of MT in this group has not yet been established. The purpose of this study is to evaluate the safety of MT in patients presenting with mild symptoms due to LVO in a large multicenter registry. Methods: STAR registry combined the prospectively maintained databases of 11 thrombectomy-capable stroke centers in the US, Europe and Asia. Patients who underwent MT were included in these analyses. Baseline features, risk factors, location of occlusion, time from symptom onset, tPA receipt, procedural complication rates, symptomatic hemorrhage, and long-term functional outcome were compared between patients with mild symptoms (NIHSS < 6) to those with severe symptoms (NIHSS ≥ 6). Results: Total of 2,114 patients were included in this analysis. Of those, 162 patients presented with NIHSS ≥ 6. Baseline features and outcomes are summarized in table 1. There was no difference in age, or sex, tPA receipt, number of attempts, rate of successful revascularization, symptomatic hemorrhage, or length of hospital stay. Median ASPECTS score was 9 in the mild Vs 8 in the severe symptom group (p=< 0.001), there was a higher percentage of patients in the mild symptom group with hypertension, hyperlipidemia, and LVO in the posterior circulation. Conversely there were more patients with atrial fibrillation in the severe symptom group. Excellent outcome (mRS 0-2 at 90 days) was achieved in 69.8% patients in the mild group compared to 38.3% in the severe group, p=<0.001) Conclusion: In patients with minor symptoms due to large vessel occlusion, mechanical thrombectomy appears to be safe with low complication rates. Approximately seventy percent of patients achieved excellent functional recovery. Table 1:

scholarly journals Endovascular therapy in patients with large vessel occlusion due to cardioembolism versus large-artery atherosclerosis

2021 ◽  
Vol 14 ◽  
pp. 175628642199901
Author(s):  
Meredeth Zotter ◽  
Eike I. Piechowiak ◽  
Rupashani Balasubramaniam ◽  
Rascha Von Martial ◽  
Kotryna Genceviciute ◽  
...  
Keyword(s):  
Heart Failure ◽  
Endovascular Therapy ◽  
Independent Predictor ◽  
Intravenous Thrombolysis ◽  
Stent Retriever ◽  
Large Vessel ◽  
Large Artery ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Significant Difference

Background and aims: To investigate whether stroke aetiology affects outcome in patients with acute ischaemic stroke who undergo endovascular therapy. Methods: We retrospectively analysed patients from the Bernese Stroke Centre Registry (January 2010–September 2018), with acute large vessel occlusion in the anterior circulation due to cardioembolism or large-artery atherosclerosis, treated with endovascular therapy (±intravenous thrombolysis). Results: The study included 850 patients (median age 77.4 years, 49.3% female, 80.1% with cardioembolism). Compared with those with large-artery atherosclerosis, patients with cardioembolism were older, more often female, and more likely to have a history of hypercholesterolaemia, atrial fibrillation, current smoking (each p < 0.0001) and higher median National Institutes of Health Stroke Scale (NIHSS) scores on admission ( p = 0.030). They were more frequently treated with stent retrievers ( p = 0.007), but the median number of stent retriever attempts was lower ( p = 0.016) and fewer had permanent stent placements ( p ⩽ 0.004). Univariable analysis showed that patients with cardioembolism had worse 3-month survival [72.7% versus 84%, odds ratio (OR) = 0.51; p = 0.004] and modified Rankin scale (mRS) score shift ( p = 0.043) and higher rates of post-interventional heart failure (33.5% versus 18.5%, OR = 2.22; p < 0.0001), but better modified thrombolysis in cerebral infarction (mTICI) score shift ( p = 0.025). Excellent (mRS = 0–1) 3-month outcome, successful reperfusion (mTICI = 2b–3), symptomatic intracranial haemorrhage and Updated Charlson Comorbidity Index were similar between groups. Propensity-matched analysis found no statistically significant difference in outcome between stroke aetiology groups. Stroke aetiology was not an independent predictor of favourable mRS score shift, but lower admission NIHSS score, younger age and independence pre-stroke were (each p < 0.0001). Stroke aetiology was not an independent predictor of heart failure, but older age, admission antithrombotics and dependence pre-stroke were (each ⩽0.027). Stroke aetiology was not an independent predictor of favourable mTICI score shift, but application of stent retriever and no permanent intracranial stent placement were (each ⩽0.044). Conclusion: We suggest prospective studies to further elucidate differences in reperfusion and outcome between patients with cardioembolism and large-artery atherosclerosis.

Abstract 1122‐000125: Underlying ICAD is Associated with Worse Outcome in Acute Large Vessel Occlusion Undergoing Endovascular Therapy

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Sonam Thind ◽  
Ali Mansour ◽  
Scott Mendelson ◽  
Elisheva Coleman ◽  
James Brorson ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Intravenous Thrombolysis ◽  
Fold Increase ◽  
Large Vessel ◽  
High Risk Population ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Intracranial Atherosclerotic Disease ◽  
Poor Outcomes

Introduction : Acute large vessel occlusion (LVO) can be secondary to thromboembolism or underlying intracranial atherosclerotic disease (ICAD). Data on the management of LVO due to underlying ICAD are scarce. We hypothesized that patients with ICAD would have worse clinical outcomes following mechanical thrombectomy (MT) than those without ICAD. Methods : We performed a retrospective analysis of consecutive patients who underwent MT for LVO in a large academic comprehensive stroke center between 01/2018 and 05/2021. Presence of underlying ICAD at the site of LVO was determined by the treating interventionalist. We compared outcomes including in‐hospital mortality and 90‐day modified Rankin Scale (mRS) between those with and without underlying ICAD, adjusting for relevant covariates using logistic regression. Results : Among 195 patients (mean age 67.4+15.1 years, 56.9% female, 81% black, median NIHSS score 15), underlying ICAD was present in 39 (20.0%). Stent‐retrievers were used 196 patients with only 3 having rescue stent placement. There were no significant differences in baseline factors amongst the two groups except diabetes was more common (69.2% vs. 49.7%, p = 0.028) and intravenous thrombolysis provided less often (17.9% vs. 36.5%, p = 0.027) in those with ICAD. TICI 2B or higher was achieved in 82.1% of ICAD compared with 94.3% of non‐ICAD patients (p = 0.012). Mortality was more common (50.0% vs. 30.8%, p = 0.025) and good functional outcome (mRS 0–2) at 90 days was less common (10.8% vs. 30.0%, p = 0.002) in the ICAD group. Adjusting for age, diabetes, intravenous thrombolysis, baseline NIHSS score, and final TICI score, underlying ICAD was an independent predictor of mRS 0–2 at 90 days (OR 4.5, 95% CI 1.4‐14.2, p = 0.010). Conclusions : Underlying ICAD is associated with 4.5‐fold increase in poor functional outcome in patients with LVO undergoing traditional MT. Further research is needed to understand factors associated with poor outcomes investigate alternative interventional approaches and medical management in this high‐risk population.

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