Abstract WP76: Artificial Intelligence CTA Vessel Density Mapping to Enhance Identification of Large Vessel Occlusions in Mobile Stroke Unit

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kevin Brown ◽  
Bryan Villareal ◽  
Kenneth Harrell ◽  
Mersedeh Bahr Hosseini ◽  
Lucas Restrepo-Jimenez ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Clinical Decision Making ◽  
Vessel Density ◽  
Large Vessel ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Stroke Units ◽  
Density Mapping ◽  
Mobile Stroke Unit

Background: Equipped with CT scanners capable of imaging the brain parenchyma and vasculature, Mobile Stroke Units (MSU) have the ability to image, diagnose and treat stroke patients in the prehospital setting. Automated CTA vessel density mapping could enhance frontline neurologist scan review in identifying large vessel occlusion (LVO), ensuring appropriate patient diagnosis and routing. Methods: We analyzed consecutive acute ischemic stroke patients undergoing CTA imaging in a regional Mobile Stroke Unit. Automated CTA vessel density mapping was performed in the field immediately after scan completion. CTA source images were wirelessly transferred to an off-site processing server (RAPID.Ai, IschemiaView) for artery reconstruction and color-coded density mapping, with blue, green, yellow, and red color shading indicating vessel density decreases of 70%-85%, 60%-75%, 45%-60%, and <45%. Results: Among all 16 patients, median processing time was 186 secs, and all images were available in time to aid clinical decision-making. Overall, automated processing yielded evaluable images in 94% (suboptimal contrast opacification precluded analysis of 1). Of the 15 diagnostically adequate exams, 100% (15/15) showed concordance for identification of anterior circulation occluded/abnormal vessel territories between automated CTA vessel density mapping and expert physician final CTA interpretation. Cases included true positives in 7, and true negatives in 8. Among true positives, CTA vessel density mapping identified the symptomatic occlusion in 6/6 and also correctly identified a severe cervical ICA stenosis unrelated to the clinical presentation in 1/1. Correctly detected intracranial occlusions included: ICA-17%. M1-17%, M1-M2 junction-17%, and M2-50%. Degree of vessel density diminution correlated with proximal-distal occlusion location. Conclusion: CTA vessel density mapping can feasibly and efficiently be conducted in Mobile Stroke Units and shows high accuracy in detection of large and medium intracranial vessel occlusions. Extension of mapping to the intracranial posterior circulation and algorithmic adjustment for proximal cervical stenoses/occlusions would further improve utility in aiding prehospital routing.

Abstract 1122‐000126: Mobile Stroke Unit Process Metrics in Large Vessel Occlusion Stroke Patients: BEST‐MSU Substudy

2021 ◽  
Vol 1 (S1) ◽  
Author(s):  
Alexandra L Czap ◽  
Anne W Alexandrov ◽  
May Nour ◽  
Noopur Singh ◽  
Mengxi Wang ◽  
...  
Keyword(s):  
Stroke Unit ◽  
Large Vessel ◽  
Categorical Variables ◽  
Continuous Variables ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Mobile Stroke Unit ◽  
Process Metrics

Introduction : Mobile Stroke Units (MSUs) speed thrombolytic treatment for acute ischemic stroke and improve clinical outcomes compared to standard management by Emergency Medical Services (EMS). However, MSU process metrics in the subset of patients with large vessel occlusions (LVOs) having endovascular thrombectomy (EVT) have yet to be optimized. Methods : A pre‐specified Benefits of Stroke Treatment Using a Mobile Stroke Unit (BEST‐MSU) substudy of tPA‐eligible stroke patients with imaging evident LVOs was conducted. The primary outcome was process metrics related to treatment times from stroke onset and first medical alert. Safety outcomes included rates of symptomatic intracerebral hemorrhage and procedural complications. Groups were compared using Chi‐square or Fisher’s exact tests for categorical variables, and Wilcoxon rank‐sum tests for continuous variables. Results : A total of 295 patients were included, 169 in the MSU group and 126 in the EMS group. Baseline characteristics were comparable between the groups, with the exception of baseline NIHSS (MSU mean 19.0 [IQR 13.0,23.0] vs EMS 16.0 [11.0, 20.0], p = 0.003). 92% of MSU and 87% of EMS LVO patients received tPA, and 78% and 85% went on to have EVT. Process metrics are detailed in Table 1. MSU LVO patients had faster tPA bolus from 911‐alert (MSU 45.0 minutes [40.0, 53.5] vs EMS 76.0 [64.0, 87.8], p<0.001), however the two groups had similar alert to groin puncture (MSU 142.5 [116.8, 171.0] versus EMS 131.5 [114.0, 159.8], p = 0.15). MSU patients spent more time on‐scene, (EMS arrival to ED arrival, 53.0 [45.0, 62.0] vs 27.0 [22.0, 33.0], p<0.001) however less time prior to EVT (door to groin puncture, 76.5 [54.8, 108.5] vs 94.0 [72.0, 123.0], p<0.001) with variable use of field CTAs and direct cath lab admission with ED bypass, yielding a net neutral result. The variability among site protocols is reflected in the range of median alert to groin puncture times (minimum 107.0 minutes, maximum 152.0). In the 222 patients undergoing EVT, median alert to recanalization time was 181.5 minutes [146.8, 225.5] in the MSU group and 190.5 [157.5, 227.5] in the EMS group (p = 0.47). Recanalization (Thrombolysis In Cerebral Infarction [TICI] 2b/3) was achieved in 76% of MSU and 70% of EMS (p = 0.32) with comparable rates of EVT complications (including hemorrhage, perforation, dissection, hematoma). 54% MSU and 44% of EMS LVO patients achieved good functional outcome (modified Rankin Scale [mRS] ≤ 2) at 90 days (p = 0.11). Conclusions : In tPA‐eligible LVO stroke patients, MSU management did not increase or expedite EVT treatment times as compared to standard EMS management. Future MSU processes should include field CTA with direct admission to cath labs to maximize the early treatment advantage this technology provides.

scholarly journals Factors associated with prominent vessel sign on susceptibility-weighted imaging in acute ischemic stroke

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Hai-fei Jiang ◽  
Yi-qun Zhang ◽  
Jiang-xia Pang ◽  
Pei-ning Shao ◽  
Han-cheng Qiu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Large Vessel ◽  
Susceptibility Weighted Imaging ◽  
Regression Analyses ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Factors Associated ◽  
Univariate Analyses

AbstractThe prominent vessel sign (PVS) on susceptibility-weighted imaging (SWI) is not displayed in all cases of acute ischemia. We aimed to investigate the factors associated with the presence of PVS in stroke patients. Consecutive ischemic stroke patients admitted within 24 h from symptom onset underwent emergency multimodal MRI at admission. Associated factors for the presence of PVS were analyzed using univariate analyses and multivariable logistic regression analyses. A total of 218 patients were enrolled. The occurrence rate of PVS was 55.5%. Univariate analyses showed significant differences between PVS-positive group and PVS-negative group in age, history of coronary heart disease, baseline NIHSS scores, total cholesterol, hemoglobin, anterior circulation infarct, large vessel occlusion, and cardioembolism. Multivariable logistic regression analyses revealed that the independent factors associated with PVS were anterior circulation infarct (odds ratio [OR] 13.7; 95% confidence interval [CI] 3.5–53.3), large vessel occlusion (OR 123.3; 95% CI 33.7–451.5), and cardioembolism (OR 5.6; 95% CI 2.1–15.3). Anterior circulation infarct, large vessel occlusion, and cardioembolism are independently associated with the presence of PVS on SWI.

scholarly journals Relationship between stroke etiology and collateral status in anterior circulation large vessel occlusion

2020 ◽  
Vol 267 (11) ◽  
pp. 3362-3370
Author(s):  
Eva Hassler ◽  
Markus Kneihsl ◽  
Hannes Deutschmann ◽  
Nicole Hinteregger ◽  
Marton Magyar ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Adverse Events ◽  
Infarct Size ◽  
Artery Occlusion ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Extracranial Carotid Artery

Abstract Background and purpose Clinical outcome after mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke is influenced by the intracerebral collateral status. We tested the hypothesis that patients with preexisting ipsilateral extracranial carotid artery stenosis (CAS) would have a better collateral status compared to non-CAS patients. Additionally, we evaluated MT-related adverse events and outcome for both groups. Methods Over a 7-year period, we identified all consecutive anterior circulation MT patients (excluding extracranial carotid artery occlusion and dissection). Patients were grouped into those with CAS ≥ 50% according to the NASCET criteria and those without significant carotid stenosis (non-CAS). Collateral status was rated on pre-treatment CT- or MR-angiography according to the Tan Score. Furthermore, we assessed postinterventional infarct size, adverse events and functional outcome at 90 days. Results We studied 281 LVO stroke patients, comprising 46 (16.4%) with underlying CAS ≥ 50%. Compared to non-CAS stroke patients (n = 235), patients with CAS-related stroke more often had favorable collaterals (76.1% vs. 46.0%). Recanalization rates were comparable between both groups. LVO stroke patients with underlying CAS more frequently had adverse events after MT (19.6% vs. 6.4%). Preexisting CAS was an independent predictor for favorable collateral status in multivariable models (Odds ratio: 3.3, p = 0.002), but post-interventional infarct size and functional 90-day outcome were not different between CAS and non-CAS patients. Conclusions Preexisting CAS ≥ 50% was associated with better collateral status in LVO stroke patients. However, functional 90-day outcome was independent from CAS, which could be related to a higher rate of adverse events.

Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000012827
Author(s):  
Adam de Havenon ◽  
Alicia Castonguay ◽  
Raul Nogueira ◽  
Thanh N. Nguyen ◽  
Joey English ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Primary Outcome ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion

ObjectiveTo determine the impact of endovascular therapy for large vessel occlusion stroke in patients with pre-morbid disability versus those without.MethodsWe performed a post-hoc analysis of the TREVO Stent-Retriever Acute Stroke (TRACK) Registry, which collected data on 634 consecutive stroke patients treated with the Trevo device as first-line EVT at 23 centers in the United States. We included patients with internal carotid or middle cerebral (M1/M2 segment) artery occlusions and the study exposure was patient- or caregiver-reported premorbid modified Rank Scale (mRS) ≥2 (premorbid disability, PD) versus premorbid mRS score 0-1 (no premorbid disability, NPD). The primary outcome was no accumulated disability, defined as no increase in 90-day mRS from the patient’s pre-morbid mRS.ResultsOf the 634 patients in TRACK, 407 patients were included in our cohort, of which 53/407 (13.0%) had PD. The primary outcome of no accumulated disability was achieved in 37.7% (20/53) of patients with PD and 16.7% (59/354) of patients with NPD (p<0.001), while death occurred in 39.6% (21/53) and 14.1% (50/354) (p<0.001), respectively. The adjusted odds ratio of no accumulated disability for PD patients was 5.2 (95% CI 2.4-11.4, p<0.001) compared to patients with NPD. However, the adjusted odds ratio for death in PD patients was 2.90 (95% CI 1.38-6.09, p=0.005).ConclusionsIn this study of anterior circulation acute ischemic stroke patients treated with EVT, we found that premorbid disability was associated with a higher probability of not accumulating further disability compared to patients with no premorbid disability, but also with higher probability of death.Classification of EvidenceThis study provides Class II evidence that in anterior circulation acute ischemic stroke treated with EVT, patients with premorbid disability compared to those without disability were more likely not to accumulate more disability but were more likely to die.


scholarly journals Mechanical Thrombectomy for Minor and Mild Stroke Patients Harboring Large Vessel Occlusion in the Anterior Circulation

Stroke ◽  
2017 ◽  
Vol 48 (12) ◽  
pp. 3274-3281 ◽  
Author(s):  
Cyril Dargazanli ◽  
Caroline Arquizan ◽  
Benjamin Gory ◽  
Arturo Consoli ◽  
Julien Labreuche ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Mild Stroke

scholarly journals Early recanalization in large-vessel occlusion stroke patients transferred for endovascular treatment

2021 ◽  
pp. neurintsurg-2021-017441
Author(s):  
Nerea Arrarte Terreros ◽  
Agnetha A E Bruggeman ◽  
Isabella S J Swijnenburg ◽  
Laura C C van Meenen ◽  
Adrien E Groot ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Functional Outcome ◽  
Clinical Improvement ◽  
Patient Characteristics ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Imaging Characteristics

BackgroundWe performed an exploratory analysis to identify patient and thrombus characteristics associated with early recanalization in large-vessel occlusion (LVO) stroke patients transferred for endovascular treatment (EVT) from a primary (PSC) to a comprehensive stroke center (CSC).MethodsWe included patients with an LVO stroke of the anterior circulation who were transferred to our hospital for EVT and underwent repeated imaging between January 2016 and June 2019. We compared patient characteristics, workflow time metrics, functional outcome (modified Rankin Scale at 90 days), and baseline thrombus imaging characteristics, which included: occlusion location, thrombus length, attenuation, perviousness, distance from terminus of intracranial carotid artery to the thrombus (DT), and clot burden score (CBS), between early-recanalized LVO (ER-LVO), and non-early-recanalized LVO (NER-LVO) patients.ResultsOne hundred and forty-nine patients were included in the analysis. Early recanalization occurred in 32% of patients. ER-LVO patients less often had a medical history of hypertension (31% vs 49%, P=0.04), and more often had clinical improvement between PSC and CSC (ΔNIHSS −5 vs 3, P<0.01), compared with NER-LVO patients. Thrombolysis administration was similar in both groups (88% vs 78%, P=0.18). ER-LVO patients had no ICA occlusions (0% vs 27%, P<0.01), more often an M2 occlusion (35% vs 17%, P=0.01), longer DT (27 mm vs 12 mm, P<0.01), shorter thrombi (17 mm vs 27 mm, P<0.01), and higher CBS (8 vs 6, P<0.01) at baseline imaging. ER-LVO patients had lower mRS scores (1 vs 3, P=0.02).ConclusionsEarly recanalization is associated with clinical improvement between PSC and CSC admission, more distal occlusions and shorter thrombi at baseline imaging, and better functional outcome.

Burden of large vessel occlusion stroke and the service gap of thrombectomy: A population-based study using a territory-wide public hospital system registry

2019 ◽  
Vol 15 (1) ◽  
pp. 69-74 ◽  
Author(s):  
Anderson C.O. Tsang ◽  
Jia You ◽  
Lai Fung Li ◽  
Frederick C.P. Tsang ◽  
Pauline P.S. Woo ◽  
...  
Keyword(s):  
Hong Kong ◽  
Ischemic Stroke ◽  
Population Based ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
The Public ◽  
Service Gap

Background Ischemic stroke due to large vessel occlusion can be effectively treated with thrombectomy but access to this treatment is limited in many parts of the world. Local incidence of large vessel occlusion is critical in determining the development of thrombectomy service, but reliable data from Asian countries are lacking. Aims We performed a population-based study to estimate the burden of large vessel occlusion and the service gap for thrombectomy in Hong Kong. Methods All acute ischemic stroke patients admitted in 2016 to the public healthcare system, which provided 90% of the emergency healthcare in the city, was identified from the Hong Kong Hospital Authority’s central electronic database. The diagnosis of large vessel occlusion was retrospectively verified by two independent cerebrovascular specialists in a randomly sampled cohort based on clinical and neuroimaging data. The incidence of large vessel occlusion in the population was estimated through weighting the sample results and compared with the thrombectomy data in the same period. Results There were 6859 acute ischemic stroke patients treated in the public health system in 2016. Amongst the 300 patients randomly sampled according to diagnosis coding, 130 suffered from anterior circulation large vessel occlusion. This translated to 918 patients (95% CI 653–1180) and 13.3% of all ischemic stroke patients. The estimated incidence of anterior circulation large vessel occlusion was 12.5 per 100,000 persons per year (95% CI 11.7–13.4). Large vessel occlusion stroke patients were more commonly female than male (67.4% vs. 31.6%, p = 0.003), and were older than non-large vessel occlusion stroke patients (mean of 80.5 years vs. 71.4 years, p = < 0.001). They also had higher 30-day mortality rate (31.1% vs. 4.6%, p = < 0.001), and longer hospital stay (mean 38.6 vs. 21.1 days, p = 0.003) than non-large vessel occlusion stroke. In the same period, 83 thrombectomies for large vessel occlusion were performed, representing 9.1% of the estimated large vessel occlusion incidence. Conclusion The estimated incidence of anterior circulation large vessel occlusion in the Hong Kong Chinese population is lower than that in the West. There is however a substantial service gap for endovascular thrombectomy with less than 10% of large vessel occlusion patients receiving thrombectomy.

DEVT: A randomized, controlled, multicenter trial of direct endovascular treatment versus standard bridging therapy for acute stroke patients with large vessel occlusion in the anterior circulation – Protocol

2020 ◽  
pp. 174749302092534
Author(s):  
Zhongming Qiu ◽  
Hansheng Liu ◽  
Fengli Li ◽  
Weidong Luo ◽  
Deping Wu ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Acute Stroke ◽  
Multicenter Trial ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Bridging Therapy ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Randomized Controlled

Background Eight randomized controlled trials have consistently shown that endovascular treatment plus best medical treatment improves outcome after acute anterior proximal intracranial large vessel occlusion strokes. Whether intravenous thrombolysis prior to endovascular treatment in patients with anterior circulation, large vessel occlusion is of any additional benefits remains unclear. Objective This study compares the safety and efficacy of direct endovascular treatment versus intravenous recombinant tissue-type plasminogen activator bridging with endovascular treatment (bridging therapy) in acute stroke patients with intracranial internal carotid artery or middle cerebral artery-M1 occlusion within 4.5 h of symptom onset. Methods and design The DEVT study is a randomized, controlled, multicenter trial with blinded outcome assessment. This trial uses a five-look group-sequential non-inferiority design. Up to 194 patients in each interim analysis will be consecutively randomized to direct endovascular treatment or bridging therapy group in 1:1 ratio over three years from about 30 hospitals in China. Outcomes The primary end-point is the proportion of independent neurological function defined as modified Rankin scale score of 0 to 2 at 90 days. The primary safety measure is symptomatic intracerebral hemorrhage at 48 h and mortality at 90 days. Trial registry number ChiCTR-IOR-17013568 ( www.chictr.org.cn ).

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