Abstract WP55: Good Collateral Status Predicts Better Outcomes in Endovascular Treatment of Acute Ischemic Stroke: A Systematic Review and Meta-Analysis

Introduction: Endovascular therapy (EVT) for the treatment of acute ischemic stroke in cervical and/or cerebral arterial occlusions is superior to standard medical therapy alone. This however requires careful patient selection and the current criteria utilising time windows and the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is imperfect, limiting its efficacy. We explore the impact of pretreatment collateral status (CS) in predicting EVT outcomes. Methods: A systematic literature search was conducted on PubMed and EMBASE for randomized controlled trials and prospective and retrospective cohort studies without language restriction from January 01, 2000 to June 25, 2019. We included studies reporting efficacy and safety outcomes dichotomised by collateral status in patients with acute anterior circulation ischemic stroke that were treated with mechanical thrombectomy and/or intra-arterial thrombolysis. Odds ratios were pooled for good versus poor collaterals for outcomes based on a random-effects model. Results: The search strategy yielded fifty-four (54) studies (n=7,599) (mean age 67.6 years; females 47.4%) for quantitative analysis, of which there were 2 pairs of studies with overlapping populations but had reported different outcomes. Thus, there were at least 7,441 unique individuals included in this analysis recruited between May 1992 and September 2018. Analysis showed that good CS was strongly associated with favourable functional outcomes (modified Rankin Scale 0-2) at discharge, as well as at 3 months or follow-up (Table 1). Good CS was also associated with higher revascularization rates, lower rates of mortality and lower rates of symptomatic intracranial hemorrhage. Conclusions: Good pretreatment CS strongly predicts good functional outcome and lower complication rates. Pretreatment CS should be considered in the design of future clinical trials and as a selection criteria for EVT.

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The impact of leptomeningeal collaterals in acute ischemic stroke

10.21203/rs.3.rs-36392/v1 ◽

2020 ◽

Author(s):

Nida Fatima ◽

Maher Saqqur ◽

Ashfaq Shuaib

Keyword(s):

Blood Flow ◽

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Meta Analysis ◽

Random Effect ◽

Random Effect Model ◽

Mesh Terms ◽

Favorable Clinical Outcome ◽

The Impact

Abstract Objectives: Leptomeningeal collaterals provide an alternate pathway to maintain cerebral blood flow in stroke to prevent ischemia, but their role in predicting outcome is still unclear. So, our study aims at assessing the significance of collateral blood flow (CBF) in acute stroke. Methods: Electronic databases were searched under different MeSH terms from Jan 2000 to Feb 2019. Studies were included if there was available data on good and poor CBF in acute ischemic stroke (AIS). The clinical outcomes included were modified rankin scale (mRS), recanalization, mortality, and symptomatic intracranial hemorrhage (sICH) at 90 days. Data was analyzed using random-effect model.Results: A total of 47 studies with 8,194 patients were included. Pooled meta-analysis revealed that there exist 2-fold higher likelihood of favorable clinical outcome (mRS≤2) at 90 days with good CBF compared with poor CBF (RR: 2.27; 95%CI: 1.94-2.65; p<0.00001) irrespective of the thrombolytic therapy [RR with IVT: 2.90; 95%CI: 2.14-3.94; p<0.00001, and RR with IAT/EVT: 1.99; 95% CI: 1.55-2.55; p<0.00001]. Moreover, there exists 1-fold higher probability of successful recanalization with good CBF (RR: 1.31; 95% CI: 1.15-1.49; p<0.00001). However, there was 54% and 64% lower risk of sICH and mortality respectively in patients with good CBF in AIS (p<0.00001).Conclusions: The relative risk of favorable clinical outcome is more in patients with good pretreatment CBF. This could be explained due to better chances of recanalization, combined with lesser risk of intracerebral hemorrhage in good CBF status.

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EXPRESS: Impact of renal impairment on short-term outcomes following endovascular thrombectomy for acute ischemic stroke: A systematic review and meta-analysis

International Journal of Stroke ◽

10.1177/17474930211047337 ◽

2021 ◽

pp. 174749302110473

Author(s):

Jin Pyeong Jeon ◽

Chih-Hao Chen ◽

Fon-Yih Tsuang ◽

Jianming Liu ◽

Michael D Hill ◽

...

Keyword(s):

Systematic Review ◽

Ischemic Stroke ◽

Renal Impairment ◽

Acute Ischemic Stroke ◽

Meta Analysis ◽

Functional Independence ◽

Continuous Variable ◽

Endovascular Thrombectomy ◽

Symptomatic Intracerebral Hemorrhage ◽

The Impact

Background. The impact of renal impairment (RI) on the outcomes of patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) was relatively limited and contradictory. We performed a systematic review and meta-analysis to investigate this. Aims. We registered a protocol on September 2020 and searched MEDLINE, EMBASE, and Google Scholar accordingly. RI was defined as an estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2. Predefined outcomes included functional independence (defined as a modified Rankin Scale of 0, 1, or 2) at 3 months, successful reperfusion, mortality, and symptomatic intracerebral hemorrhage (sICH). Summary of review. Eleven studies involving 3453 patients were included. For the unadjusted outcomes, RI was associated with fewer functional independence (odds ratio (OR), 0.49; 95% confidence interval (CI), 0.39â0.62) and higher mortality (OR, 2.55; 95% CI, 2.03â3.21). RI was not associated with successful reperfusion (OR, 0.80; 95% CI 0.63â1.00) and sICH (OR, 1.41; 95% CI, 0.95â2.10). For the adjusted outcomes, results derived from a multivariate meta-analysis were consistent with the respective unadjusted outcomes: functional independence (OR, 0.59; 95% CI, 0.45â0.77), mortality (OR, 2.23, 95% CI, 1.45â3.43), and sICH (OR, 1.34; 95% CI, 0.85â2.10). Conclusions. We presented the first systematic review to demonstrate that RI is associated with fewer functional independence and higher mortality. Future EVT studies should publish complete renal eGFR data to facilitate prognostic studies and permit eGFR to be analyzed in a continuous variable. Systematic Review Registration: PROSPERO CRD42020191309

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Workflow Intervals of Endovascular Acute Stroke Therapy During On- Versus Off-Hours

Stroke ◽

10.1161/strokeaha.119.025381 ◽

2019 ◽

Vol 50 (10) ◽

pp. 2842-2850 ◽

Cited By ~ 3

Author(s):

Wouter H. Hinsenveld ◽

Inger R. de Ridder ◽

Robert J. van Oostenbrugge ◽

Jan A. Vos ◽

Adrien E. Groot ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Large Vessel ◽

Complication Rates ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Significant Difference

Background and Purpose— Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours. Methods— We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models. Results— We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar. Conclusions— Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.

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Management of acute ischemic stroke

BMJ ◽

10.1136/bmj.l6983 ◽

2020 ◽

pp. l6983 ◽

Cited By ~ 15

Author(s):

Michael S Phipps ◽

Carolyn A Cronin

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Treatment Time ◽

Recurrent Stroke ◽

Time Windows ◽

Intravenous Thrombolysis ◽

Stroke Care ◽

Developed Countries ◽

Future Research ◽

The Impact

ABSTRACT Stroke is the leading cause of long term disability in developed countries and one of the top causes of mortality worldwide. The past decade has seen substantial advances in the diagnostic and treatment options available to minimize the impact of acute ischemic stroke. The key first step in stroke care is early identification of patients with stroke and triage to centers capable of delivering the appropriate treatment, as fast as possible. Here, we review the data supporting pre-hospital and emergency stroke care, including use of emergency medical services protocols for identification of patients with stroke, intravenous thrombolysis in acute ischemic stroke including updates to recommended patient eligibility criteria and treatment time windows, and advanced imaging techniques with automated interpretation to identify patients with large areas of brain at risk but without large completed infarcts who are likely to benefit from endovascular thrombectomy in extended time windows from symptom onset. We also review protocols for management of patient physiologic parameters to minimize infarct volumes and recent updates in secondary prevention recommendations including short term use of dual antiplatelet therapy to prevent recurrent stroke in the high risk period immediately after stroke. Finally, we discuss emerging therapies and questions for future research.

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Groin complications in endovascular mechanical thrombectomy for acute ischemic stroke: a 10-year single center experience

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2015-011763 ◽

2015 ◽

Vol 8 (6) ◽

pp. 568-570 ◽

Cited By ~ 17

Author(s):

Veer A Shah ◽

Coleman O Martin ◽

Angela M Hawkins ◽

William E Holloway ◽

Shilpa Junna ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Mechanical Thrombectomy ◽

Complication Rates ◽

Artery Pseudoaneurysm ◽

Stroke Treatment ◽

Vascular Closure Devices ◽

Clinical Records ◽

The Impact ◽

Groin Hematoma

BackgroundThe increasing utilization of balloon guide catheters (BGCs) in thrombectomy therapy for ischemic stroke has led to concerns about large-bore sheaths causing vascular groin complications.Objective To retrospectively assess the impact of large large-bore sheaths and vascular closure devices on groin complication rates at a comprehensive stroke center over a 10-year period.MethodsRadiological and clinical records of patients with acute ischemic stroke who underwent mechanical endovascular therapy with an 8Fr or larger sheaths were reviewed. A groin complication was defined as the formation of a groin hematoma, retroperitoneal hematoma, femoral artery pseudoaneurysm, or the need for surgical repair. Information collected included size of sheath, type of hemostatic device, and anticoagulation status of the patient. Blood bank records were also analyzed to identify patients who may have had an undocumented blood transfusion for a groin hematoma.ResultsA total of 472 patients with acute ischemic stroke who underwent mechanical thrombectomy with a sheath and BGC sized 8Fr or larger were identified. 260 patients (55.1%) had tissue Plasminogen Activator (tPA) administered as part of stroke treatment. Vascular closure devices were used in 97.9% of cases (n=462). Two patients were identified who had definite groin complications and a further two were included as having possible complications. There was a very low rate of clinically significant groin complications (0.4–0.8%) associated with the use of large-bore sheaths.ConclusionsThese findings suggest that concerns for groin complications should not preclude the use of BGCs and large-bore sheaths in mechanical thrombectomy for acute ischemic stroke.

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Diagnosis of DWI-negative acute ischemic stroke

Neurology ◽

10.1212/wnl.0000000000004120 ◽

2017 ◽

Vol 89 (3) ◽

pp. 256-262 ◽

Cited By ~ 39

Author(s):

Brian L. Edlow ◽

Shelley Hurwitz ◽

Jonathan A. Edlow

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Clinical Diagnosis ◽

Clinical Characteristics ◽

Meta Analysis ◽

Reperfusion Therapy ◽

Posterior Circulation ◽

Anterior Circulation ◽

Ovid Medline ◽

Level Data

Objective:To determine the prevalence of diffusion-weighted imaging (DWI)–negative acute ischemic stroke (AIS) and to identify clinical characteristics of patients with DWI-negative AIS.Methods:We systematically searched PubMed and Ovid/MEDLINE for relevant studies between 1992, the year that the DWI sequence entered clinical practice, and 2016. Studies were included based upon enrollment of consecutive patients presenting with a clinical diagnosis of AIS prior to imaging. Meta-analysis was performed to synthesize study-level data, estimate DWI-negative stroke prevalence, and estimate the odds ratios (ORs) for clinical characteristics associated with DWI-negative stroke.Results:Twelve articles including 3,236 AIS patients were included. The meta-analytic synthesis yielded a pooled prevalence of DWI-negative AIS of 6.8%, 95% confidence interval (CI) 4.9–9.3. In the 5 studies that reported proportion data for DWI-negative and DWI-positive AIS based on the ischemic vascular territory (n = 1,023 AIS patients), DWI-negative stroke was strongly associated with posterior circulation ischemia, as determined by clinical diagnosis at hospital discharge or repeat imaging (OR 5.1, 95% CI 2.3–11.6, p < 0.001).Conclusions:A small but significant percentage of patients with AIS have a negative DWI scan. Patients with neurologic deficits consistent with posterior circulation ischemia have 5 times the odds of having a negative DWI scan compared to patients with anterior circulation ischemia. AIS remains a clinical diagnosis and urgent reperfusion therapy should be considered even when an initial DWI scan is negative.

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A direct aspiration first-pass technique vs stentriever thrombectomy in emergent large vessel intracranial occlusions

Journal of Neurosurgery ◽

10.3171/2016.11.jns161563 ◽

2018 ◽

Vol 128 (2) ◽

pp. 567-574 ◽

Cited By ~ 30

Author(s):

Christopher J. Stapleton ◽

Thabele M. Leslie-Mazwi ◽

Collin M. Torok ◽

Reza Hakimelahi ◽

Joshua A. Hirsch ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Scale Score ◽

Large Vessel ◽

Initial Attempt ◽

Anterior Circulation ◽

Endovascular Thrombectomy ◽

Standard Medical Therapy ◽

First Pass ◽

Procedural Time

OBJECTIVEEndovascular thrombectomy in patients with acute ischemic stroke caused by occlusion of the proximal anterior circulation arteries is superior to standard medical therapy. Stentriever thrombectomy with or without aspiration assistance was the predominant technique used in the 5 randomized controlled trials that demonstrated the superiority of endovascular thrombectomy. Other studies have highlighted the efficacy of a direct aspiration first-pass technique (ADAPT).METHODSTo compare the angiographic and clinical outcomes of ADAPT versus stentriever thrombectomy in patients with emergent large vessel occlusions (ELVO) of the anterior intracranial circulation, the records of 134 patients who were treated between June 2012 and October 2015 were reviewed.RESULTSWithin this cohort, 117 patients were eligible for evaluation. ADAPT was used in 47 patients, 20 (42.5%) of whom required rescue stentriever thrombectomy, and primary stentriever thrombectomy was performed in 70 patients. Patients in the ADAPT group were slightly younger than those in the stentriever group (63.5 vs 69.4 years; p = 0.04); however, there were no differences in the other baseline clinical or radiographic factors. Procedural time (54.0 vs 77.1 minutes; p < 0.01) and time to a Thrombolysis in Cerebral Infarction (TICI) scale score of 2b/3 recanalization (294.3 vs 346.7 minutes; p < 0.01) were significantly lower in patients undergoing ADAPT versus stentriever thrombectomy. The rates of TICI 2b/3 recanalization were similar between the ADAPT and stentriever groups (82.9% vs 71.4%; p = 0.19). There were no differences in the rates of symptomatic intracranial hemorrhage or procedural complications. The rates of good functional outcome (modified Rankin Scale Score 0–2) at 90 days were similar between the ADAPT and stentriever groups (48.9% vs 41.4%; p = 0.45), even when accounting for the subset of patients in the ADAPT group who required rescue stentriever thrombectomy.CONCLUSIONSThe present study demonstrates that ADAPT and primary stentriever thrombectomy for acute ischemic stroke due to ELVO are equivalent with respect to the rates of TICI 2b/3 recanalization and 90-day mRS scores. Given the reduced procedural time and time to TICI 2b/3 recanalization with similar functional outcomes, an initial attempt at recanalization with ADAPT may be warranted prior to stentriever thrombectomy.

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Impact of Glycosylated Hemoglobin on the Prognosis of Patients with Acute Ischemic Stroke Treated with Arterial Thrombolysis

The Heart Surgery Forum ◽

10.1532/hsf.2929 ◽

2020 ◽

Vol 23 (4) ◽

pp. E447-E451

Author(s):

Wentong Ling ◽

Qiong Chen ◽

Pu Huang ◽

Dengke Han ◽

Wenjun Wu

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Hba1c Level ◽

Poor Prognosis ◽

Glycosylated Hemoglobin ◽

Complication Rates ◽

Nihss Score ◽

Prognosis Group ◽

The Impact ◽

Arterial Thrombolysis

Background: To investigate the impact of glycosylated hemoglobin (HbA1c) on the prognosis of patients with acute ischemic stroke (AIS) treated with intra-arterial thrombolysis (IAT). Methods: The clinical data of 136 patients with AIS treated with IAT at the Zhongshan City People’s Hospital were retrospectively analyzed. The patients were divided into a high HbA1c group (HHbA1c) (≥6.5%) and a normal HbA1c group (NHbA1c) (<6.5%). According to National Institutes of Health Stroke Scale (NIHSS) score after thrombolysis, patients were divided into a good prognosis group (GP) (≥4 or <4 points reduction) and a poor prognosis group (PP) (≤4 or >4 points reduction). Results: There were significant differences in the HbA1c and glucose levels, NIHSS scores at admission and at discharge, complication rates, and mortality rates between groups HHbA1c and NHbA1c (P < .05) and between groups GP and PP (P < .05). The multivariate logistic regression analysis showed that HbA1c level (odds ratio [OR] 0.717; 95% confidence interval [CI] 0.545 to 0.889) and NIHSS score at admission (OR 0.894; 95% CI 0.814 to 0.982) were risk factors for neurological improvement in IAT-treated patients with AIS. Conclusions: HbA1c level is associated with neurological function improvement in IAT-treated patients with AIS and can be used as a serological indicator of poor prognosis.

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Quality of life and cost consequence of delays in endovascular treatment for acute ischemic stroke in China

Health Economics Review ◽

10.1186/s13561-021-00352-w ◽

2022 ◽

Vol 12 (1) ◽

Author(s):

Weiyi Ni ◽

Wolfgang G. Kunz ◽

Mayank Goyal ◽

Lijin Chen ◽

Yawen Jiang

Keyword(s):

Ischemic Stroke ◽

Cost Effectiveness ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Healthcare Costs ◽

Time Window ◽

Time Windows ◽

Sensitivity Analyses ◽

Health State ◽

The Impact

Abstract Background Although endovascular therapy (EVT) improves clinical outcomes in patients with acute ischemic stroke, the time of EVT initiation significantly influences clinical outcomes and healthcare costs. This study evaluated the impact of EVT treatment delay on cost-effectiveness in China. Methods A model combining a short-term decision tree and long-term Markov health state transition matrix was constructed. For each time window of symptom onset to EVT, the probability of receiving EVT or non-EVT treatment was varied, thereby varying clinical outcomes and healthcare costs. Clinical outcomes and cost data were derived from clinical trials and literature. Incremental cost-effectiveness ratio and incremental net monetary benefits were simulated. Deterministic and probabilistic sensitivity analyses were performed to assess the robustness of the model. The willingness-to-pay threshold per quality-adjusted life-year (QALY) was set to ¥71,000 ($10,281). Results EVT performed between 61 and 120 min after the stroke onset was most cost-effective comparing to other time windows to perform EVT among AIS patients in China, with an ICER of ¥16,409/QALY ($2376) for performing EVT at 61–120 min versus the time window of 301–360 min. Each hour delay in EVT resulted in an average loss of 0.45 QALYs and 165.02 healthy days, with an average net monetary loss of ¥15,105 ($2187). Conclusions Earlier treatment of acute ischemic stroke patients with EVT in China increases lifetime QALYs and the economic value of care without any net increase in lifetime costs. Thus, healthcare policies should aim to improve efficiency of pre-hospital and in-hospital workflow processes to reduce the onset-to-puncture duration in China.

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Brain Atrophy and the Risk of Futile Endovascular Reperfusion in Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.119.028511 ◽

2020 ◽

Vol 51 (5) ◽

pp. 1514-1521 ◽

Cited By ~ 3

Author(s):

María I. Pedraza ◽

Mercedes de Lera ◽

Daniel Bos ◽

Ana I. Calleja ◽

Elisa Cortijo ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Brain Atrophy ◽

Regression Models ◽

Infarct Volume ◽

Cortical Atrophy ◽

Anterior Circulation ◽

Evans Index ◽

The Impact

Background and Purpose— We aimed to evaluate the impact of brain atrophy on long-term clinical outcome in patients with acute ischemic stroke treated with endovascular therapy, and more specifically, to test whether there are interactions between the degree of atrophy and infarct volume, and between atrophy and age, in determining the risk of futile reperfusion. Methods— We studied consecutive patients with acute ischemic stroke with proximal anterior circulation intracranial arterial occlusions treated with endovascular therapy achieving successful arterial recanalization. Brain atrophy was evaluated on baseline computed tomography with the global cortical atrophy scale, and Evans index was calculated to assess subcortical atrophy. Infarct volume was assessed on control computed tomography at 24 hours using the formula for irregular volumes (A×B×C/2). Main outcome variable was futile recanalization, defined by functional dependence (modified Rankin Scale score >2) at 3 months. The predefined interactions of atrophy with age and infarct volume were studied in regression models. Results— From 361 consecutive patients with anterior circulation acute ischemic stroke treated with endovascular therapy, 295 met all inclusion criteria. Futile reperfusion was observed in 144 out of 295 (48.8%) patients. Cortical atrophy affecting parieto-occipital and temporal regions was associated with futile recanalization. Total global cortical atrophy score and Evans index were independently associated with futile recanalization in an adjusted logistic regression. Multivariable adjusted regression models disclosed significant interactions between global cortical atrophy score and infarct volume (odds ratio, 1.003 [95%CI, 1.002–1.004], P <0.001) and between global cortical atrophy score and age (odds ratio, 1.001 [95% CI, 1.001–1.002], P <0.001) in determining the risk of futile reperfusion. Conclusions— A higher degree of cortical and subcortical brain atrophy is associated with futile endovascular reperfusion in anterior circulation acute ischemic stroke. The impact of brain atrophy on insufficient clinical recovery after endovascular reperfusion appears to be independently amplified by age and by infarct volume.

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