Abstract TP32: Efficacy and Safety of Hyper-acute Stenting for Symptomatic Intracranial Atherosclerotic Disease

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Alexander McQuinn ◽  
Andrew Cheung ◽  
Jason Wenderoth ◽  
Amer Mitchelle ◽  
Christopher Blair ◽  
...  
Keyword(s):  
Symptom Onset ◽  
Ct Perfusion ◽  
Early Postoperative Period ◽  
Atherosclerotic Disease ◽  
Target Vessel ◽  
Efficacy And Safety ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Intracranial Atherosclerotic Disease ◽  
Select Group

Introduction: Recent data suggests stenting of symptomatic intracranial atherosclerotic disease (ICAD) in the hyper-acute period (< 8 days of symptom onset) is associated with a high incidence of early postoperative morbidity and mortality. We assessed the efficacy and safety of this select group of patients at our institutions. Methods: Between December 2017 to May 2019, anterior circulation stroke patients who underwent acute stenting of symptomatic intracranial atherosclerotic disease with the Atlas stent (Stryker) were identified from a prospectively maintained database of stroke patients at two comprehensive stroke centres. Baseline characteristics, imaging, and clinical outcomes are reported. Results: Nine cases were identified (mean age 71years, 44.4% male, median NIHSS 9 (range 5-18)). All patients had baseline mRS of 3 or less. Median time from symptom onset to groin puncture was 10hours (range 4-96hours). All patients received dual-antiplatelet therapy with Aspirin and Prasugrel(DAPT) either immediately before or after the procedure. In patients who did not receive pre-procedure loading with DAPT (55.6%), a single intravenous dose of Abciximab (mean 9mg +/- 4mg) or Tirofiban (1mg) was given intra-operatively. No thromboembolic complications or mortality occurred in the early postoperative period (within 72hours). All patients showed improvement in target vessel perfusion on day-one CT-perfusion. At 90-days, 7 (77.8%) patients were either functionally independent (mRS 0-2) or at their pre-operative baseline. No symptomatic intracranial haemorrhage occurred. No recurrent target vessel strokes were recorded. One patient died of medical complications unrelated to intracranial stenting and one patient was mRS 3 at 90-days. Conclusion: Hyper-acute stenting of symptomatic ICAD may be safe and effective. Antiplatelet treatment strategies and advances in stent devices may be critical in the success of this approach.

scholarly journals Plaque morphology in acute symptomatic intracranial atherosclerotic disease

2020 ◽  
pp. jnnp-2020-325027
Author(s):  
Thomas W Leung ◽  
Li Wang ◽  
Xinying Zou ◽  
Yannie Soo ◽  
Yuehua Pu ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Three Dimensional ◽  
Morphological Features ◽  
Atherosclerotic Disease ◽  
Sensitivity Analyses ◽  
Plaque Morphology ◽  
Stroke Subtype ◽  
Anterior Circulation ◽  
Intracranial Atherosclerotic Disease ◽  
Ulcerative Lesions

BackgroundIntracranial atherosclerotic disease (ICAD) is globally a major ischaemic stroke subtype with high recurrence. Understanding the morphology of symptomatic ICAD plaques, largely unknown by far, may help identify vulnerable lesions prone to relapse.MethodsWe prospectively recruited patients with acute ischaemic stroke or transient ischaemic attack attributed to high-grade ICAD (60%–99% stenosis). Plaque morphological parameters were assessed in three-dimensional rotational angiography, including surface contour, luminal stenosis, plaque length/thickness, upstream shoulder angulation, axial/longitudinal plaque distribution and presence of adjoining branch atheromatous disease (BAD). We compared morphological features of smooth, irregular and ulcerative plaques and correlated them with cerebral ischaemic lesion load downstream in MRI.ResultsAmong 180 recruited patients (median age=60 years; 63.3% male; median stenosis=75%), plaque contour was smooth (51 (28.3%)), irregular (101 (56.1%)) or ulcerative (28 (15.6%)). Surface ulcers were mostly at proximal (46.4%) and middle one-third (35.7%) of the lesions. Most (84.4%) plaques were eccentric, and half had their maximum thickness over the distal end. Ulcerative lesions were thicker (medians 1.6 vs 1.3 mm; p=0.003), had steeper upstream shoulder angulation (56.2° vs 31.0°; p<0.001) and more adjoining BAD (83.3% vs 57.0%; p=0.033) than non-ulcerative plaques. Ulcerative plaques were significantly associated with coexisting acute and chronic infarcts downstream (35.7% vs 12.5%; adjusted OR 4.29, 95% CI 1.65 to 11.14, p=0.003). Sensitivity analyses in patients with anterior-circulation ICAD lesions showed similar results in the associations between the plaque types and infarct load.ConclusionsUlcerative intracranial atherosclerotic plaques were associated with vulnerable morphological features and had a higher cumulative infarct load downstream.

scholarly journals Prospective Endovascular Treatment in Acute Ischemic Stroke Evaluating Non-Contrast Head CT versus CT Perfusion (PLEASE No CTP)

2019 ◽  
Vol 8 (2-6) ◽  
pp. 116-122
Author(s):  
Ameer E. Hassan ◽  
Hafsah Shamim ◽  
Haralabos Zacharatos ◽  
Saqib A. Chaudhry ◽  
Christina Sanchez ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Ct Perfusion ◽  
Treatment Decision ◽  
Anterior Circulation ◽  
Nihss Score ◽  
Contrast Ct

Background: Studies have shown a lack of agreement of computed tomography perfusion (CTP) in the selection of acute ischemic stroke (AIS) patients for endovascular treatment. Purpose: To demonstrate whether non-contrast computed tomography (CT) within 8 h of symptom onset is comparable to CTP imaging. Methods: Prospective study of consecutive anterior circulation AIS patients with a National Institute of Health Stroke Scale (NIHSS) score > 7 presenting within 8 h of symptom onset with endovascular treatment. All patients had non-contrast CT, CT angiography, and CTP. The neuro-interventionalist was blinded to the results of the CTP and based the treatment decision using the Alberta Stroke Program Early CT score (ASPECTS). Baseline demographics, co-morbidities, and baseline NIHSS scores were collected. Outcomes were modified Rankin scale (mRS) score at discharge and in-hospital mortality. Good outcomes were defined as a mRS score of 0–2. Results: 283 AIS patients were screened for the trial, and 119 were enrolled. The remaining patients were excluded for: posterior circulation stroke, no CTP performed, could not obtain consent, and NIHSS score < 7. Mean ­NIHSS score at admission was 16.8 ± 3, and mean ASPECTS was 8.4 ± 1.4. There was no statistically significant correlation with CTP penumbra and good outcomes: 50 versus 47.8% with no penumbra present (p = 0.85). In patients without evidence of CTP penumbra, there was 22.5% mortality compared to 22.1% mortality in patients with a CTP penumbra. If ASPECTS ≥7, 64.6% had good outcome versus 13.3% if ASPECTS < 7 (p < 0.001). Patients with an ASPECTS ≥7 had 10% mortality versus 51.4% in patients with an ASPECTS < 7 (p < 0.001). Conclusions: CTP penumbra did not identify patients who would benefit from endovascular treatment when patients were selected with non-contrast CT ASPECTS ≥7. There is no correlation of CTP penumbra with good outcomes or mortality. Larger prospective trials are warranted to justify the use of CTP within 6 h of symptom onset.

Abstract WMP15: A Simple Tool to Predict Target Mismatch in Ischemic Stroke Patients with Anterior Circulation Occlusion

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Adam de Havenon ◽  
Steve O’Donnell ◽  
Alex Linn ◽  
Scott McNally ◽  
Bailey Dunleavy ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Perfusion Imaging ◽  
Time Window ◽  
Ct Perfusion ◽  
Volumetric Analysis ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Ct Angiogram

Introduction: The efficacy of endovascular thrombectomy in an extended time window for acute ischemic stroke patients with Target Mismatch (TM) on perfusion imaging was shown in a recent study and the ongoing DEFUSE-3 trial is studying thrombectomy in a 6-16 hour window for TM patients. A limitation of TM is that perfusion imaging is not widely available. We sought to identify a tool to predict TM based on clinical factors and CT angiogram (CTA) imaging, which is available at most hospitals. Methods: We reviewed acute ischemic stroke patients from 2010-2014 with proximal middle cerebral artery occlusion, CTA and CT perfusion (CTP) at hospital admission. TM was identified on CTP using the Olea Sphere volumetric analysis software with Bayesian deconvolution. TM was defined by the DEFUSE-3 criteria. ASPECTS was derived from the non-contrast CT head and the CTA source images (CTA-ASPECTS). Two collateral scores were derived from CTA source images. Results: 61 patients met inclusion criteria. The mean±SD age was 61±18 years and 61% were male. Mean NIH Stroke Scale (NIHSS) was 14.1±8.0 and median (IQR) follow-up modified Rankin Scale was 3 (1,6). TM was present in 35/61 (57%), who had lower mRS at follow-up (z=3.5, p<0.001). The predictor variables are shown in Table 1. The best combination of predictors was CTA-ASPECTS >4 and NIHSS <16, which had a sensitivity of 80% and specificity of 85% for TM (Figure 1). Discussion: We report a reliable, accessible, and clinically useful tool for predicting TM. This score warrants further study as a tool to guide transfer decisions from primary or secondary stroke centers to tertiary centers where endovascular intervention would be possible for selected patients.

Abstract TP49: Irreversible Ischemic Lesion Characterization: Does CBV_ASPECTS Add to CT_ASPECTS?

Stroke ◽  
2016 ◽  
Vol 47 (suppl_1) ◽  
Author(s):  
Marina Padroni ◽  
Pilar Coscojuela ◽  
Sandra Boned ◽  
Marc Ribó ◽  
Jordi Cabero ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Symptom Onset ◽  
Cerebral Blood Volume ◽  
Ct Perfusion ◽  
Infarct Volume ◽  
Relevant Information ◽  
Artery Occlusion ◽  
Carotid Artery Occlusion ◽  
Anterior Circulation ◽  
Ischemic Lesion

Introduction: The best technique for selecting acute stroke patients for reperfusion therapies is not defined yet. ASPECTS is a useful score for assessing the extent of early ischemic signs in the anterior circulation on non-contrast CT (CT). Cerebral blood volume (CBV) on CT perfusion (CTP) defines the core lesion assumed to be irreversibly damaged. Whether CBV provides additional information over CT in the initial ASPECTS assessment is unknown. We aim to explore the advantages of CBV_ASPECTS over CT_ASPECTS in the prediction of final infarct volume. Methods: Consecutive patients with middle cerebral or internal carotid artery occlusion who underwent endovascular reperfusion treatment according to initial CT_ASPECTS≥7 were studied. CBV_ASPECTS was assessed blindly later-on. Recanalization was defined as TICI2b3. Final infarct volumes were measured on follow-up imaging. We defined an irrelevant ASPECTS difference (IAD) as: CT_ASPECTS - CBV_ASPECTS≤1. Results: Sixty-five patients, mean age 67±14, median NIHSS:16(10-20) were studied. Recanalization rate was: 78.5%. Median CT_ASPECTS was 9(8-10), and CBV_ASPECTS 8(8-10). Mean time from symptom onset to CT was 219±143 min. 50 patients (76.9%) showed an IAD. The ASPECTS difference was inversely correlated to the time from symptom onset to CT (r:-0.36, p<0.01). A ROC curve defined 120 minutes as the best cut-off time point after which the ASPECTS difference becomes irrelevant. The rate of IAD was significantly higher after 120 minutes (89.5% Vs 37.5; p<0.01). CBV_ASPECTS but not CT_ASPECTS correlated to the final infarct (r:-0.33, p<0.01). However, if CT was done >2 hours after symptom onset, then CT_ASPECTS was correlated to final infarct (r:-0.39, p=0.01). No other variables were associated with CT-CBV_ASPECTS difference. Conclusions: In acute stroke patient CBV_ASPECTS correlates with final infarct volume. However, when CT is performed after 120 minutes from symptoms onset CBV_ASPECTS does not add relevant information to CT_ASPECTS.

Abstract TP51: Does Intracranial Atherosclerotic Disease With Low NIHSS Effect Outcomes in Reperfusion Therapy Eligible Acute Stroke Patients?

Stroke ◽  
2018 ◽  
Vol 49 (Suppl_1) ◽  
Author(s):  
Manabu Inoue ◽  
Michael Mlynash ◽  
Shinichi Wada ◽  
Masatoshi Koga ◽  
Joji Nakagawara ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Reperfusion Therapy ◽  
Atherosclerotic Disease ◽  
Stroke Patients ◽  
Intracranial Atherosclerotic Disease

Direct Intra-arterial thrombectomy in order to Revascularize AIS patients with large vessel occlusion Efficiently in Chinese Tertiary hospitals: A Multicenter randomized clinical Trial (DIRECT-MT)—Protocol

2019 ◽  
Vol 15 (6) ◽  
pp. 689-698 ◽  
Author(s):  
Pengfei Yang ◽  
Kilian M Treurniet ◽  
Lei Zhang ◽  
Yongwei Zhang ◽  
Zifu Li ◽  
...  
Keyword(s):  
Lower Boundary ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Atherosclerotic Disease ◽  
Considerable Proportion ◽  
Probe Design ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Intracranial Atherosclerotic Disease

Rationale Intravenous thrombolysis combined with mechanical thrombectomy (MT) has been proven safe and clinical effective in patients with acute ischemic stroke of anterior circulation large vessel occlusion. However, despite reperfusion, a considerable proportion of patients do not recover. Incidence of symptomatic intracerebral hemorrhage was similar between patients treated with the combination of intravenous thrombolysis and MT, as compared to intravenous thrombolysis alone, suggesting that this complication should be attributed to pre-treatment with intravenous thrombolysis. Conversely, intravenous thrombolysis may be beneficial in patients with small clots occluding intracranial arteries with underlying intracranial atherosclerotic disease, not accessible for MT. Aim To assess whether direct MT is non-inferior compared to combined intravenous thrombolysis plus MT in patients with AIS due to an anterior circulation large vessel occlusion, and to assess treatment effect modification by presence of intracranial atherosclerotic disease. Sample size Aim to randomize 636 patients 1:1 to receive direct MT (intervention) or combined intravenous thrombolysis plus MT (control). Design This is a multicenter, prospective, open label parallel group trial with blinded outcome assessment (PROBE design) assessing non-inferiority of direct MT compared to combined intravenous thrombolysis plus MT. Outcomes The primary outcome is the score on the modified Rankin Scale assessed blindly at 90 (±14) days. An common odds ratio, adjusted for the prognostic factors (age, NIHSS, collateral score), representing the shift on the 6-category mRS scale measured at three months, estimated with ordinal logistic regression, will be the primary effect parameter. Non-inferiority is established if the lower boundary of the 95% confidence interval does not cross 0.8. Discussion DIRECT-MT could result in improved therapeutic efficiency and cost reduction in treatment of anterior circulation large vessel occlusion stroke.

scholarly journals Automated CT Perfusion Prediction of Large Vessel Acute Stroke from Intracranial Atherosclerotic Disease

2018 ◽  
Vol 7 (6) ◽  
pp. 334-340 ◽  
Author(s):  
Diogo C. Haussen ◽  
Mehdi Bouslama ◽  
Seena Dehkharghani ◽  
Jonathan A. Grossberg ◽  
Nicolas Bianchi ◽  
...  
Keyword(s):  
Ldl Cholesterol ◽  
Ct Perfusion ◽  
Systolic Pressure ◽  
Large Vessel ◽  
Atherosclerotic Disease ◽  
Vessel Occlusion ◽  
Intracranial Atherosclerotic Disease ◽  
Baseline Characteristics ◽  
Ischemic Core ◽  
Hba1c Levels

Background and Purpose: We have observed that large vessel occlusion acute strokes (LVOS) due to intracranial atherosclerotic disease (ICAD) present with more benign CT perfusion (CTP) profiles, which we presume to potentially represent enhanced collateralization compared to embolic LVOS. We aim to determine if CTP profiles can predict ICAD in LVOS. Methods: Retrospective review of a prospectively collected interventional stroke database from September 2010 to March 2015. Patients with intracranial ICA/MCA-M1/M2 occlusions and CTP were dichotomized into ICAD versus non-ICAD etiologies. Ischemic core (relative cerebral blood flow < 30%) and hypoperfusion volumes were estimated by automated CTP. Results: A total of 250 patients met the inclusion criteria, comprised of 21 (8%) ICAD and 229 non-ICAD etiologies. Baseline characteristics were similar between groups, except for higher HbA1c levels (p < 0.01), LDL cholesterol (p < 0.01), systolic blood pressure (p < 0.01), and lower rate of atrial fibrillation (p < 0.01) in ICAD patients. There were no significant differences in volumes of baseline ischemic core (p = 0.54) among groups. ICAD patients had smaller Tmax > 4 s, Tmax > 6 s, and Tmax > 10 s absolute lesions, and a higher ratio of Tmax > 4 s/Tmax > 6 s volumes (median 2 [1.6–2.3] vs. 1.6 [1.4–2.0]; p = 0.02). A Tmax > 4 s/Tmax > 6 s ratio ≥2 showed specificity = 73%/sensitivity = 52% for ICAD and was observed in 47.6% of ICAD versus 26.1% of non-ICAD patients (p = 0.07). Clinical outcomes were comparable amongst groups. Multivariate logistic regression revealed that Tmax > 4 s/Tmax > 6 s ratio ≥2 (OR 3.75, 95% CI 1.05–13.14, p = 0.04), higher LDL cholesterol (OR 1.1, 95% CI 1.01–1.03, p = 0.01), and higher systolic pressure (OR 1.03, 95% CI 1.01–1.04, p = 0.01) were independently associated with ICAD. Conclusion: An automated CTP Tmax > 4 s/Tmax > 6 s ratio ≥2 profile was found independently associated with underlying ICAD LVOS.

scholarly journals First-line contact aspiration vs stent-retriever thrombectomy in acute ischemic stroke patients with large-artery occlusion in the anterior circulation: Systematic review and meta-analysis

2019 ◽  
Vol 25 (3) ◽  
pp. 244-253 ◽  
Author(s):  
Marion Boulanger ◽  
Bertrand Lapergue ◽  
Francis Turjman ◽  
Emmanuel Touzé ◽  
René Anxionnat ◽  
...  
Keyword(s):  
Functional Independence ◽  
Artery Occlusion ◽  
Stent Retriever ◽  
Large Artery ◽  
Line Contact ◽  
Efficacy And Safety ◽  
Stroke Patients ◽  
First Line ◽  
Anterior Circulation ◽  
Excellent Outcome

Background In acute ischemic stroke patients with large-artery occlusion, uncertainties remain about whether clinically important outcomes are comparable between first-line contact aspiration and stent-retriever thrombectomy, although two trials have investigated whether one strategy should be preferred over another. Purpose The purpose of this article is to compare the efficacy and safety of first-line contact aspiration and stent-retriever thrombectomy in stroke patients with anterior circulation large-artery occlusion. Methods We undertook a systematic review of studies of patients treated for large-artery occlusion, with the latest devices of either strategy, within six hours of stroke onset. We determined rates of final complete reperfusion (defined as modified Thrombolysis In Cerebral Infarction score = 3), periprocedural complications and 90-day functional independence (defined as modified Rankin Scale (mRS) score 0–2), and excellent outcome (defined as mRS score 0–1) after contact aspiration and after stent-retriever thrombectomy using random-effects meta-analyses. Any differential effects in rates between the two strategies were assessed using random-effects meta-regressions. Results Fifteen studies (1817 patients) were included. There was no difference in rates of final complete reperfusion at the end of all endovascular procedures between contact aspiration and stent retrievers (51.1%, 95% confidence interval (CI) 39.3–62.9; vs 38.3%, 95% CI 28.6–48.0; pint = 0.14), 90-day functional independence (45.0%, 40.7–49.2; vs 52.4%, 47.7–57.1; pint = 0.45) and excellent outcome (32.1%, 25.7–38.5; vs 34.1%, 21.2–46.9; pint = 0.94). Rates of periprocedural complications did not differ between the two strategies. Conclusions Current data suggest no difference in efficacy and safety between first-line contact aspiration and stent-retriever thrombectomy in stroke patients with large-artery occlusion.

Abstract TP40: Time From Stroke Onset to Reperfusion is Associated With Worse Functional Outcomes in Patients With Rapidly Progressing Infarcts

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Anson Wang ◽  
Sumita Strander ◽  
Sreeja Kodali ◽  
Andrew Silverman ◽  
Alexandra Kimmel ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Symptom Onset ◽  
Functional Outcomes ◽  
Time Window ◽  
Ct Perfusion ◽  
Infarct Volume ◽  
Acute Stroke Care ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Slow Progressors

Introduction: Recent trials have demonstrated the benefit of endovascular therapy (EVT) beyond 6 hours of symptom onset. However, the importance of time to reperfusion (TTR) in the extended time window has recently been questioned. Given the variability of infarct growth rate (IGR), the time delay until reperfusion may have greater consequences for those with rapidly progressing infarcts, and identifying such patients is essential for improving outcomes. We tested the hypothesis that TTR is more closely associated with functional outcome in patients with rapidly progressing infarcts compared to their slow-progressing counterparts. Methods: We retrospectively identified 106 patients at our center’s prospectively collected stroke database with anterior circulation large-vessel occlusion stroke and known time of symptom onset. Patients underwent initial CT perfusion imaging (CTP), EVT and and follow-up MRI at 24 hours. Core infarct volumes at presentation (CBF<30%) were estimated using RAPID software. The time between symptom onset and CTP was used to estimate IGR and to categorize patients as fast (≥5 mL/hour) or slow (<5 mL/hour) progressors. Alternatively, final infarct volume (FIV) was measured on MRI and used to calculate IGR in the absence of CTP. Functional outcome was assessed using the modified Rankin scale (mRS) at discharge and 90 days. Associations were computed using ordinal regression adjusting for age, ASPECTS, and TICI. Results: 35 fast progressors (age 71±14, 17 F, TTR 288±91 minutes, mean IGR 21±24 mL/hour) and 71 slow progressors (age 71±17, 48 F, TTR 374±211 minutes, mean IGR 1.0±1.5 mL/hour) were identified. Fast progressors had higher admission NIHSS scores (18±6 vs 13±7, p<0.001) and significantly larger FIV (101±77 vs 47±65 mL, p<0.001). After adjusting for baseline factors, TTR was significantly associated with worse functional outcome at 90 days in fast progressors (p=0.026, aOR 1.13 per 10 minutes, 95% CI 1.02-1.28), but not for slow progressors (p=0.708). Conclusions: In patients with rapidly progressing infarcts (≥5 mL/hour), TTR was associated with worse functional outcomes at 90 days compared to slow progressors. Identifying such patients may be critical for appropriate triage and rapid delivery of acute stroke care.

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