Abstract WP19: Reliability of CT Perfusion in the Posterior Circulation in Comparison to the Anterior Circulation

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Srijan Adhikari ◽  
Justin Moore ◽  
Abid Y Qureshi
Keyword(s):  
Ct Perfusion ◽  
Infarct Volume ◽  
Posterior Circulation ◽  
Large Vessel ◽  
Anterior Circulation ◽  
Kendall’S Tau ◽  
Mean Velocity ◽  
Vessel Occlusion ◽  
Kendall's Tau ◽  
Nonparametric Correlation

Background: DAWN and DEFUSE-3 excluded posterior-circulation cases, but in practice endovascular therapy (EVT) is common due to life-threatening large-vessel occlusions. Often CT perfusion (CTP) is acquired to aid in the decision-making of these cases, but the reliability of using CT perfusion in the posterior-circulation is unknown Hypothesis: Given the differences in hemodynamics (~20% of total CBF to the basilar, reduced mean velocity, and differences in collateral supply) penumbra estimates using RAPID software will be less accurate in predicting the final infarct volume on DWI. Methods: In patients who did not receive any treatment (tPA or EVT), the Tmax >6s, as operationally defined as penumbra, should approximate the infarct on DWI. As such, only posterior circulation patients without EVT or tPA were included. Anterior circulation patients were matched on demographics, medical history, outcomes. A ratio of Tmax/DWI was calculated to assess how closely perfusion approximated final infarct folume. Nonparametric correlation with Kendall’s tau-b was also performed. Results: Eleven patients with a posterior circulation large-vessel occlusion (pc-LVO) were compared to 30-matched patients with anterior circulation (ac-LVO). Age was 62.4±16 for ac-LVO vs. 64.5±13 for pc-LVO. Significant differences were seen in sex with ac-LVO 82% male, and pc-LVO 46% male (t=-2.06 p=0.046). Pc-LVO also had more subjects with an unknown last known well. Mean admission NIHSS was 15.6±8 ac-LVO, and 16.4±10 in pc-LVO group was similar. Mean discharge NIHSS was 12.6±9 ac-LVO vs 12.4±10 pc-LVO. NO signficicant difference in 30d mRS, 24h NIHSS, or mortality within 90d. As excpected in the anterior circulation cases final infarct volume correlated with Tmax>6s Kendall’s tau-b=0.57 (p=0.000013), and Tmax>8s (tau-b=0.55), Tmax>10s (tau-b=0.55. Whereas, In the posterior circulation Tmax>6s (tau-b=0.41, N.S.), but Tmax>8s (tau-b=0.64, p=0.007) and Tmax>10(tau-b=0.69, p=0.005). Seen another way the ratio of Tmax>6s:DWI = 2.47 (ac-LVO) vs 5.84 (pc-LVO) (t=-1.22, p=0.004, but Tmax>8s 1.57 vs 1.50 (t=0.11, p=9.12). Conclusion: Final infarct volume was not significantly associated with Tmax>6s in posterior circulation cases. Instead Tmax>8s is more reliable.

Endovascular Therapy for Large Vessel Stroke in the Elderly: Hope in the New Stroke Era

2016 ◽  
Vol 42 (5-6) ◽  
pp. 421-427 ◽  
Author(s):  
Andrey Lima ◽  
Diogo C. Haussen ◽  
Leticia C. Rebello ◽  
Seena Dehkharghani ◽  
Jonathan Grossberg ◽  
...  
Keyword(s):  
Elderly Patients ◽  
Ct Perfusion ◽  
Infarct Volume ◽  
The Elderly ◽  
Outcome Data ◽  
Large Vessel ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Good Outcome

Background and Purpose: Acute ischemic stroke (AIS) in the elderly encompasses approximately one-third of all AIS cases. Outcome data have been for the most part discouraging in this population. We aim to evaluate the outcomes in a large contemporary series of elderly patients treated with thrombectomy. Methods: Retrospective analysis of a single-center endovascular database for consecutive elderly (≥80 years) patients treated for anterior circulation large vessel occlusion AIS between September 2010 and April 2015. Univariate- and multivariate analyses were performed to identify the predictors of good clinical outcome (90-day modified Ranking Scale [mRS] ≤2). Receiver operating characteristic curves were used to calculate the optimal final infarct volume (FIV) threshold to predict good outcomes. Results: A total of 111 patients met our inclusion criteria (mean age 84.8 ± 4.2 years; National Institutes of Health Stroke Scale [NIHSS] score 19.1 ± 5.6; time from last-known normal to puncture, 349.6 ± 246.6 min; 33% male; 68% Alberta Stroke Program Early CT Score [ASPECTS] ≥8). The rates of successful reperfusion (modified treatment in cerebral ischemia ≥2b), symptomatic intracranial hemorrhage and 90-day mortality were 80%, 7% and 41%, respectively. The overall rate of good outcome was 29% (n = 32/111) but was 52% (n = 13/25) in patients with baseline mRS score of 0-2 who were selected based on CT perfusion and treated with stent retrievers. On multivariate analysis, only ASPECTS (OR 2.17; 95% CI 1.28-3.67.7; p = 0.004) and baseline NIHSS score (OR 0.87; 95% CI 0.77-0.97; p = 0.013) were independently associated with good outcome. A FIV ≤16 ml demonstrated the greatest accuracy for identifying good outcomes (sensitivity 75.0%, specificity 82.6%). Conclusions: Our results are encouraging demonstrating nearly one-third of elderly patients achieving full independence at 90 days. Contemporary treatment paradigms employing optimized patient selection and modern thrombectomy technology may result in even better outcomes.

Abstract WP82: Evaluation of Infarct Core Determination in Patients With Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Victor Lopez-Rivera ◽  
James Fan ◽  
Songmi Lee ◽  
Aditya Kumar ◽  
Mehmet Enes Inam ◽  
...  
Keyword(s):  
Ct Perfusion ◽  
Infarct Volume ◽  
Large Vessel ◽  
Late Time ◽  
Large Vessel Occlusion ◽  
Mri Findings ◽  
Infarct Core ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Optimal Method

Introduction: Estimation of infarct core (IC) is a critical component in the evaluation of patients with large vessel occlusion (LVO) for endovascular stroke therapy (EST), but the optimal method to determine IC is uncertain. Methods: From our prospectively maintained institutional registry, we identified acute ischemic stroke (AIS) patients with LVO between 1/2018 and 2/2019. Patients were included if they underwent consecutively and technically adequate non-contrast CT, CT angiography (CTA), and CT Perfusion (CTP). ASPECTS was assessed by an experienced neuroradiologist. CTP IC was determined using RAPID. Final infarct volume (FIV) was determined by manual volume segmentation on DWI sequences from 24h MRI, but this analysis was limited to patients who underwent EST with TICI 2b/3 reperfusion within 120 minutes of presentation CT imaging, to minimize IC growth affecting the results. Correlation between IC measurements was calculated using Spearman p. Results are provided as median [IQR]. Results: Among 772 patients with LVO, 199 patients met inclusion criteria. Median age was 69 [59-79], 47% were female and 57% were white. Median NIHSS was 15 [9-21], the most common occlusion site was M1 MCA (55%). Median CT ASPECTS was 7 [6-9], median CTA ASPECTS was 6 [5-7], and median CTP-RAPID IC volume was 11 [0-47]. Presentation CT ASPECTS correlated with CTP-RAPID IC (Fig. 1A, r=-0.57; p<0.0001), as did CTA ASPECTS (Fig. 1B, r=-0.61; p<0.0001). Presentation CTA ASPECTS correlated with CTP-RAPID IC in patients presenting 0-6 hrs (CTA r=-0.69; p<0.0001) and 6-24 hrs (r=-0.58; p<0.0001). Among 90 patients with EST and TICI 2b/3, presentation CTA ASPECTS correlated better with FIV (r=-0.65; p<0.0001) compared to presentation CTP-RAPID (r=0.61; p<0.0001). Conclusions: In patients with LVO in the anterior circulation, CTA ASPECTS correlated well with CTP-RAPID IC in the early and late time windows, and was more reflective of 24h MRI findings in patients who received EST.

Abstract 31: Penumbra Consumption Rates Based on T Max Delay and Reperfusion Status: A Post-Hoc Analysis of the Defuse-3 Trial

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shadi Yaghi ◽  
Eytan Raz ◽  
Seena Dehkharghani ◽  
Howard Riina ◽  
Ryan McTaggart ◽  
...  
Keyword(s):  
Infarct Volume ◽  
Secondary Analysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Consumption Rates ◽  
Definition Of ◽  
Post Hoc ◽  
New Generation

Introduction: In patients with acute large vessel occlusion, the definition of penumbral tissue based on T max delay perfusion imaging is not well established in relation to late-window endovascular thrombectomy (EVT). In this study, we sought to evaluate penumbra consumption rates for T max delays in patients treated between 6 and 16 hours from last known normal. Methods: This is a secondary analysis of the DEFUSE-3 trial, which included patients with an acute ischemic stroke due to anterior circulation occlusion within 6-16 hours of last known normal. The primary outcome is percentage penumbra consumption defined as (24 hour infarct volume-core infarct volume)/(Tmax volume-baseline core volume). We stratified the cohort into 4 categories (untreated, TICI 0-2a, TICI 2b, and TICI3) and calculated penumbral consumption rates. Results: We included 143 patients, of which 66 were untreated, 16 had TICI 0-2a, 46 had TICI 2b, and 15 had TICI 3. In untreated patients, a median (IQR) of 48% (21% - 85%) of penumbral tissue was consumed based on Tmax6 as opposed to 160.6% (51% - 455.2%) of penumbral tissue based on Tmax10. On the contrary, in patients achieving TICI 3 reperfusion, a median (IQR) of 5.3% (1.1% - 14.6%) of penumbral tissue was consumed based on Tmax6 and 25.7% (3.2% - 72.1%) of penumbral tissue based on Tmax10. Conclusion: Contrary to prior studies, we show that at least 75% of penumbral tissue with Tmax > 10 sec delay can be salvaged with successful reperfusion and new generation devices. In untreated patients, since infarct expansion can occur beyond 24 hours, future studies with delayed brain imaging are needed to determine the optimal T max delay threshold that defines penumbral tissue in patients with proximal anterior circulation large vessel occlusion.

Prognostic importance of CT ASPECTS and CT perfusion measures of infarction in anterior emergent large vessel occlusions

2018 ◽  
Vol 11 (7) ◽  
pp. 670-674 ◽  
Author(s):  
Syed Ali Raza ◽  
Clara M Barreira ◽  
Gabriel M Rodrigues ◽  
Michael R Frankel ◽  
Diogo C Haussen ◽  
...  
Keyword(s):  
Ct Perfusion ◽  
Area Under The Curve ◽  
Large Vessel ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Median Baseline ◽  
Ct Head ◽  
Prognostic Importance ◽  
Contrast Ct

BackgroundAge, neurologic deficits, core volume (CV), and clinical core or radiographic mismatch are considered in selection for endovascular therapy (ET) in anterior circulation emergent large vessel occlusion (aELVO). Semiquantitative CV estimation by Alberta Stroke Programme Early CT Score (CT ASPECTS) and quantitative CV estimation by CT perfusion (CTP) are both used in selection paradigms.ObjectiveTo compare the prognostic value of CTP CV with CT ASPECTS in aELVO.MethodsPatients in an institutional endovascular registry who had aELVO, pre-ET National Institutes of Health Stroke Scale (NIHSS) score, non-contrast CT head and CTP imaging, and prospectively collected 3-month modified Rankin Scale (mRS) score were included. Age- and NIHSS-adjusted models, including either CT ASPECTS or CTP volumes (relative cerebral blood flow <30% of normal tissue, total hypoperfusion, and radiographic mismatch), were compared using receiver operator characteristic analyses.ResultsWe included 508 patients with aELVO (60.8% M1 middle cerebral artery, 34% internal carotid artery, mean age 64.1±15.3 years, median baseline NIHSS score 16 (12–20), median baseline CT ASPECTS 8 (7–9), mean CV 16.7±24.8 mL). Age, pre-ET NIHSS, CT ASPECTS, CV, hypoperfusion, and perfusion imaging mismatch volumes were predictors of good outcome (mRS score 0–2). There were no differences in prognostic accuracies between reference (age, baseline NIHSS, CT ASPECTS; area under the curve (AUC)=0.76) and additional models incorporating combinations of age, NIHSS, and CTP metrics including CV, total hypoperfusion or mismatch volume (AUCs 0.72–0.75). Predicted outcomes from CT ASPECTS or CTP CV-based models had excellent agreement (R2=0.84, p<0.001).ConclusionsIncorporating CTP measures of core or penumbral volume, instead of CT ASPECTS, did not improve prognostication of 3-month outcomes, suggesting prognostic equivalence of CT ASPECTS and CTP CV.

Abstract TP74: Aspects Scoring Applied to CTA Source Images is Predictive of Final Infarct Volume and Good Functional Outcome

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Joseph F Carrera ◽  
Joseph H Donahue ◽  
Prem P Batchala ◽  
Andrew M Southerland ◽  
Bradford B Worrall
Keyword(s):  
Linear Regression ◽  
Functional Outcome ◽  
Infarct Volume ◽  
Univariate Analysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
The Impact

Introduction: CTP and MRI are increasingly used to assess endovascular thrombectomy (EVT) candidacy in large vessel occlusion stroke. Unfortunately, availability of these advanced neuroimaging techniques is not widespread and this can lead to over-triage to EVT-capable centers. Hypothesis: ASPECTS scoring applied to computed tomography angiography source images (CTA-SI) will be predictive of final infarct volume (FIV) and functional outcome. Methods: We reviewed data from consecutive patients undergoing EVT at our institution for anterior circulation occlusion between 01/14 - 01/19. We recorded demographics, comorbidities, NIHSS, treatment time parameters, and outcomes as defined by mRS (0-2 = good outcome). Cerebrovascular images were assessed by outcome-blinded raters and collateral score, TICI score, FIV, and both CT and CTA-SI ASPECTS scores were noted. Patients were grouped by ASPECTS score into low (0-4), intermediate (5-7), and high (8-10) for some analyses. FIV was predicted using a linear regression with NIHSS, good reperfusion (TICI 2b/3), collateral score, CT to groin puncture, CT and CTA-SI ASPECTS as independent variables. After excluding those with baseline mRS≥2, a binary logistic regression was performed including covariates of age, NIHSS, good reperfusion, and diabetes (factors significant at p<0.05 on univariate analysis) to assess the impact of CTA-SI ASPECTS group on outcome. Results: Analysis included 137 patients for FIV and 102 for outcome analysis (35 excluded for baseline mRS≥ 2). Linear regression found CTA-SI ASPECTS (Beta -10.8, p=0.002), collateral score (Beta -42.9, p=0.001) and good reperfusion (Beta 72.605, p=0.000) were independent predictors of FIV. Relative to the low CTA-SI ASPECTS group, the high CTA-SI ASPECTS group was more likely to have good outcome (OR 3.75 [95% CI 1.05-13.3]; p=0.41). CT ASPECTS was not predictive of FIV or good outcome. Outcomes: In those undergoing EVT for anterior circulation occlusion, CTA-SI ASPECTS is predictive of both FIV and functional outcome, while CT ASPECTS predicts neither. CTA-SI ASPECTS holds promise as a lower-cost, more widely available option for triage of patients with large vessel occlusion. Further study is needed comparing CTA-SI ASPECTS to CTP parameters.

Abstract TP72: Localization of Large Vessel Occlusion (LVO) Stroke in the Posterior Circulation Based on Perfusion Imaging

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Carlo W Cereda ◽  
Jeremy Heit ◽  
Abid Qureshi ◽  
Archana Hinduja ◽  
Mikayel Grigoryan ◽  
...  
Keyword(s):  
Perfusion Imaging ◽  
Primary Outcome Measure ◽  
Posterior Circulation ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Rater Agreement ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Intracranial Vessel ◽  
Imaging Results

Introduction: The vascular territory of an occluded large intracranial vessel can be reliably identified by CT or MR perfusion imaging. Furthermore, prior studies have shown that perfusion imaging can reliably predict the specific vessel that is occluded in anterior circulation large vessel strokes. We evaluated whether perfusion imaging can predict the specific vessel occlusion (vertebral, basilar, or posterior cerebral) in posterior circulation strokes. Hypothesis: We hypothesized that the occluded vessel could be inferred from the perfusion imaging results in >80% of patients with an acute stroke due to large vessel occlusion in the posterior circulation using the simultaneous CTA or MRA as the gold standard. Furthermore, the inter-rater agreement between a vascular neurologist and a neuroradiologist would be > 90%. Agreement Coefficients (AC1) were determined. Methods: From a multicenter cohort of consecutive patients with posterior circulation stroke, we included patients with documented occlusion of the Basilar Artery (BA) posterior cerebral Artery (PCA) or vertebral artery (VA) who had perfusion imaging (MRI or CT) processed by RAPID software. Perfusion images were evaluated blinded to the angiography or any other brain imaging results. The primary outcome measure was agreement on LVO location based on the CTA/MRA results. Results: 74 patients were eligible: age 63±2, female 32%, median NIHSS 15 (IQR 5-24). The distribution of large vessel occlusions on CTA/MRA was BA (74%), PCA (14%) and VA (12%). Perfusion imaging was able to correctly predict the occluded vessel in 63 (85%), AC1 = 0.82 (95% CI 0.72-0.92), p<0.001. Interrater agreement (n=41) was high [AC1 = 0.94 (95% CI 0.87-1.0), p < 0.001]. Conclusion: Perfusion imaging can predict the site of vessel occlusion (vertebral, basilar, or posterior cerebral) in posterior circulation strokes with good accuracy and high inter-rater agreement.

A human brain test bed for research in large vessel occlusion stroke

2021 ◽  
pp. 1-9
Author(s):  
Daniel Gebrezgiabhier ◽  
Yang Liu ◽  
Adithya S. Reddy ◽  
Evan Davis ◽  
Yihao Zheng ◽  
...  
Keyword(s):  
Human Brain ◽  
Mechanical Thrombectomy ◽  
Posterior Circulation ◽  
Large Vessel ◽  
Suction Catheter ◽  
Large Vessel Occlusion ◽  
Test Bed ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Human Brains

OBJECTIVEEndovascular removal of emboli causing large vessel occlusion (LVO)–related stroke utilizing suction catheter and/or stent retriever technologies or thrombectomy is a new standard of care. Despite high recanalization rates, 40% of stroke patients still experience poor neurological outcomes as many cases cannot be fully reopened after the first attempt. The development of new endovascular technologies and techniques for mechanical thrombectomy requires more sophisticated testing platforms that overcome the limitations of phantom-based simulators. The authors investigated the use of a hybrid platform for LVO stroke constructed with cadaveric human brains.METHODSA test bed for embolic occlusion of cerebrovascular arteries and mechanical thrombectomy was developed with cadaveric human brains, a customized hydraulic system to generate physiological flow rate and pressure, and three types of embolus analogs (elastic, stiff, and fragment-prone) engineered to match mechanically and phenotypically the emboli causing LVO strokes. LVO cases were replicated in the anterior and posterior circulation, and thrombectomy was attempted using suction catheters and/or stent retrievers.RESULTSThe test bed allowed radiation-free visualization of thrombectomy for LVO stroke in real cerebrovascular anatomy and flow conditions by transmural visualization of the intraluminal elements and procedures. The authors were able to successfully replicate 105 LVO cases with 184 passes in 12 brains (51 LVO cases and 82 passes in the anterior circulation, and 54 LVO cases and 102 passes in the posterior circulation). Observed recanalization rates in this model were graded using a Recanalization in LVO (RELVO) scale analogous to other measures of recanalization outcomes in clinical use.CONCLUSIONSThe human brain platform introduced and validated here enables the analysis of artery-embolus-device interaction under physiological hemodynamic conditions within the unmodified complexity of the cerebral vasculature inside the human brain.

Abstract 132: Final Infarct Volume is a Critical Determinant of Hospitalization Cost in Anterior Circulation Large Vessel Occlusion Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Christopher Streib ◽  
Srikant Rangaraju ◽  
Daniel G Winger ◽  
David T Campbell ◽  
Stephanie Paolini ◽  
...  
Keyword(s):  
Infarct Volume ◽  
Cost Effective ◽  
Large Vessel ◽  
Sensitivity Analyses ◽  
Large Vessel Occlusion ◽  
Primary Analysis ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Critical Determinant ◽  
Hospitalization Cost

Background: Anterior circulation large vessel occlusion (ACLVO) stroke, one of the most devastating stroke subtypes, is associated with substantial economic burden. Identifying predictors of increased ACLVO stroke hospitalization cost is essential to developing cost-effective treatment strategies. Methods: We utilized comprehensive patient-level cost-tracking software to calculate hospitalization costs for ACLVO stroke patients at our institution between July 2012-October 2014. Patient demographics and neuroimaging findings were analyzed. Predictors of hospitalization cost were determined using multivariable linear regression. In addition to our primary analysis (all eligible ACLVO patients), we conducted subgroup analyses by treatment (endovascular, IV tPA-only, and no reperfusion therapy) and sensitivity analyses. Results: 341 patients (median age 69 [IQR 57-80], median NIHSS 16 [IQR 13-21], median hospitalization cost $16,446 [IQR $9823-$27,165]) were included in our primary analysis; final infarct volume (FIV), parenchymal hematoma, age, obstructive sleep apnea, and baseline NIHSS were significant predictors of hospitalization cost (Figure). FIV alone accounted for 20.51% of the total variance in hospitalization cost. Notably, FIV was consistently the most robust predictor of increased cost across primary, subgroup, and sensitivity analyses. Over the observed range of FIVs in our cohort, each additional 1cc of infarcted brain tissue increased hospitalization cost by $122.35. Conclusion: FIV is a critical determinant of increased hospitalization cost in ACLVO stroke. Therapies resulting in reduced FIV may not only improve clinical outcomes, but prove cost-effective.

Abstract TP42: Equivalent Favorable Outcomes Possible After Thrombectomy for Posterior Circulation Large Vessel Occlusion Compared to Anterior Circulation: The MUSC Experience

Stroke ◽  
2018 ◽  
Vol 49 (Suppl_1) ◽  
Author(s):  
Ali M Alawieh ◽  
Raymond D Turner ◽  
Aquilla S Turk ◽  
Mohammad I Chaudry ◽  
Jonathan Lena ◽  
...  
Keyword(s):  
Posterior Circulation ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion
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