Abstract P514: Clinically Approximated Hypoperfused Tissue in Large Vessel Occlusion Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shashvat Desai ◽  
Santiago Ortega ◽  
Sunil Sheth ◽  
Mudassir Farooqui ◽  
Victor Lopez Rivera ◽  
...  
Keyword(s):  
Conversion Factor ◽  
Time Window ◽  
Clinical Severity ◽  
Large Vessel ◽  
Late Time ◽  
Large Vessel Occlusion ◽  
Eligibility Criteria ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Derivation Cohort

Introduction: Patient selection for thrombectomy of acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) in the delayed time window (>6 hours) is dependent on delineation of clinical-core mismatch or radiological target mismatch using perfusion imaging. Selection paradigms not involving advanced imaging and software processing may reduce time to treatment and broaden eligibility. We aim to develop a conversion factor to approximately determine the volume of hypoperfused tissue using the NIHSS score [CAT volume (clinically approximated tissue)] and explore its ability to identify patients eligible for thrombectomy in the late time window. Methods: We performed a retrospective analysis of anterior circulation LVO strokes at three comprehensive stroke centers. Demographic, clinical (NIHSS score, TLKW-time last known well) and imaging [computed tomography with perfusion (CTP) processed using RAPID, IschemaView] information was analyzed. A conversion factor, which is a multiple of the NIHSS score (one multiple for NIHSS score <10 and another for NIHSS score ≥10), was derived to calculate CAT volumes. Accuracy (sensitivity and specificity) of CAT-based thrombectomy eligibility criteria (similar to DEFUSE-3 criteria but using CAT volume instead of Tmax >6 seconds volume) was tested using DEFUSE-3 criteria eligibility as a gold standard. Result: Of the 309 LVO strokes [mean age of 70 ±14, 46% male, median NIHSS 16 (12-20)] included in this study, 38% of patients arrived beyond 6 hours of TLKW. Conversion factors derived (derivation cohort-center A:187) based on median (50 th percentile) values of Tmax >6s volume for NIHSS <10 subgroup was 15 and for NIHSS ≥10 subgroup was 6. Subsequently calculated CAT volume-based eligibility criteria yielded a sensitivity of 100% and specificity of 92% in detecting DEFUSE-3 eligible patients (AUC-0.92 CI-0.82-1) in the validation cohort (center B and C:122). Conclusions: Clinical severity of stroke (NIHSS score) may be used to calculate the volume of hypoperfused tissue during LVO stroke. Clinically approximated hypoperfused tissue (CAT) volumes for NIHSS score <10 (using a factor of 15) and ≥10 (using a factor of 6) subgroups can accurately identify DEFUSE-3 eligible patients.

scholarly journals Clinically Approximated Hypoperfused Tissue in Large Vessel Occlusion Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Shashvat M. Desai ◽  
Santiago Ortega-Gutierrez ◽  
Sunil A. Sheth ◽  
Mudassir Farooqui ◽  
Victor Lopez-Rivera ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Conversion Factor ◽  
Time Window ◽  
Clinical Severity ◽  
Large Vessel ◽  
Late Time ◽  
Large Vessel Occlusion ◽  
Eligibility Criteria ◽  
Vessel Occlusion ◽  
Nihss Score

Background and Purpose: Patient selection for thrombectomy of acute ischemic stroke caused by large vessel occlusion in the delayed time window (>6 hours) is dependent on delineation of clinical-core mismatch or radiological target mismatch using perfusion imaging. Selection paradigms not involving advanced imaging and software processing may reduce time to treatment and broaden eligibility. We aim to develop a conversion factor to approximately determine the volume of hypoperfused tissue using the National Institutes of Health Stroke Scale (NIHSS) score (clinically approximated hypoperfused tissue [CAT] volume) and explore its ability to identify patients eligible for thrombectomy in the late-time window. Methods: We performed a retrospective analysis of anterior circulation large vessel occlusion strokes at 3 comprehensive stroke centers. Demographic, clinical, and imaging (computed tomography perfusion processed using RAPID, IschemaView) information was analyzed. A conversion factor, which is a multiple of the NIHSS score (for NIHSS score <10 and ≥10), was derived from an initial cohort to calculate CAT volumes. Accuracy of CAT-based thrombectomy eligibility criteria (using CAT volume instead of Tmax >6 seconds volume) was tested using DEFUSE-3 criteria (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) eligibility as a gold standard in an independent cohort. Results: Of the 309 large vessel occlusion strokes (age, 70±14, 46% male, median NIHSS 16 [12–20]) included in this study, 38% of patients arrived beyond 6 hours of time from last known well. Conversion factors derived (derivation cohort-center A: 187) based on median values of Tmax>6 second volume for NIHSS score <10 subgroup was 15 and for NIHSS score ≥10 subgroup was 6. Subsequently calculated CAT volume–based eligibility criteria yielded a sensitivity of 100% and specificity of 92% in detecting DEFUSE-3 eligible patients (area under the curve, 0.92 [95% CI, 0.82–1]) in the validation cohort (center B and C:122). Conclusions: Clinical severity of stroke (NIHSS score) may be used to calculate the volume of hypoperfused tissue during large vessel occlusion stroke. CAT volumes for NIHSS score <10 (using a factor of 15) and ≥10 (using a factor of 6) subgroups can accurately identify DEFUSE-3-eligible patients.

scholarly journals Mobile Interventional Stroke Teams Improve Outcomes in the Early Time Window for Large Vessel Occlusion Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Jacob R. Morey ◽  
Xiangnan Zhang ◽  
Naoum Fares Marayati ◽  
Stavros Matsoukas ◽  
Emily Fiano ◽  
...  
Keyword(s):  
Scale Score ◽  
Time Window ◽  
Early Time ◽  
National Institutes Of Health ◽  
Large Vessel ◽  
Late Time ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy

Background and Purpose: Endovascular thrombectomy for large vessel occlusion stroke is a time-sensitive intervention. The use of a Mobile Interventional Stroke Team (MIST) traveling to Thrombectomy Capable Stroke Centers to perform endovascular thrombectomy has been shown to be significantly faster with improved discharge outcomes, as compared with the drip-and-ship (DS) model. The effect of the MIST model stratified by time of presentation has yet to be studied. We hypothesize that patients who present in the early window (last known well of ≤6 hours) will have better clinical outcomes in the MIST model. Methods: The NYC MIST Trial and a prospectively collected stroke database were assessed for patients undergoing endovascular thrombectomy from January 2017 to February 2020. Patients presenting in early and late time windows were analyzed separately. The primary end point was the proportion with a good outcome (modified Rankin Scale score of 0–2) at 90 days. Secondary end points included discharge National Institutes of Health Stroke Scale and modified Rankin Scale. Results: Among 561 cases, 226 patients fit inclusion criteria and were categorized into MIST and DS cohorts. Exclusion criteria included a baseline modified Rankin Scale score of >2, inpatient status, or fluctuating exams. In the early window, 54% (40/74) had a good 90-day outcome in the MIST model, as compared with 28% (24/86) in the DS model ( P <0.01). In the late window, outcomes were similar (35% versus 41%; P =0.77). The median National Institutes of Health Stroke Scale at discharge was 5.0 and 12.0 in the early window ( P <0.01) and 5.0 and 11.0 in the late window ( P =0.11) in the MIST and DS models, respectively. The early window discharge modified Rankin Scale was significantly better in the MIST model ( P <0.01) and similar in the late window ( P =0.41). Conclusions: The MIST model in the early time window results in better 90-day outcomes compared with the DS model. This may be due to the MIST capturing high-risk fast progressors at an earlier time point. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03048292.

Abstract 3183: Prognosis of Mild Ischemic Stroke with Large Vessel Occlusion

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Esteban Cheng-Ching ◽  
Russell Cerejo ◽  
Ken Uchino ◽  
Muhammad S Hussain ◽  
Gabor Toth
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Therapy ◽  
Time Window ◽  
Optimal Treatment ◽  
Large Vessel ◽  
Stroke Severity ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Mild Stroke

Background and purpose Large vessel occlusion (LVO) in acute ischemic stroke has been reported to be an independent predictor of unfavorable clinical outcome. However, the prognosis and optimal treatment of patients with only mild neurologic deficits due to LVO are not known. Methods We performed a retrospective chart review from a database of stroke patients admitted to our large academic medical center between July 1, 2010 and June 30 , 2011. Inclusion criteria were acute stroke or TIA, presentation within 9 hours from symptom onset, large vessel occlusion as a culprit of ischemic symptoms, and mild stroke severity with initial NIH Stroke Scale (NIHSS) score <8. Results We identified 59 patients with mild ischemic stroke or TIA, who were evaluated within 9 hours from onset. Of these, 13 (22%) had culprit large vessel occlusions. Five were female, 1 had diabetes, 12 had hypertension, 7 had hyperlipidemia, 2 had atrial fibrillation and 7 were smokers. The median NIHSS score was 5. The location of arterial occlusions were 5 in M1 segment of the middle cerebral artery (MCA), 6 in M2 segment of MCA, 1 each in posterior cerebral and vertebral arteries. Two patients received acute therapy, 1 with intravenous thrombolysis and 1 with endovascular therapy. Reasons for withholding thrombolytic therapy were time window in 8, mild stroke severity in 2, and atypical presentations in 2. Reasons for withholding acute endovascular therapy were mild stroke severity in 7, imaging finding in 2, technical considerations in 2, and lack of consent in 1. From hospital admission to discharge, 10 (77%) patients had symptom improvement, 2 had worsening, and one was unchanged. At 30 days, 5 (38%) had good outcome with a modified Rankin Scale (mRS) of 0-1. Three (23%) had mRS of 2, one (8%) patient had mRS of 3. Outcomes for 4 patients were unknown. Conclusions A significant proportion of patients presenting with mild ischemic symptoms has large vessel occlusion. Acute treatment in this population is frequently withheld due to mild severity or thrombolytic time window. Despite mild symptoms at presentation, some patients are left with moderate disability. Optimal treatment options for this population should be further evaluated in a larger group of patients.

scholarly journals Implications of limiting mechanical thrombectomy to patients with emergent large vessel occlusion meeting top tier evidence criteria

2016 ◽  
Vol 9 (3) ◽  
pp. 225-228 ◽  
Author(s):  
Rohini Bhole ◽  
Nitin Goyal ◽  
Katherine Nearing ◽  
Andrey Belayev ◽  
Vinodh T Doss ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Time Window ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Strict Adherence ◽  
Nihss Score ◽  
Neurological Improvement ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Increased Risk

BackgroundRecent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence would have impacted treatment numbers and outcomes in a cohort of patients from a comprehensive stroke center.MethodsA retrospective observational study was conducted using consecutive emergent endovascular patients. Mechanical thrombectomy (MT) was performed with stent retrievers or large bore clot aspiration catheters. Procedural outcomes were compared between patients meeting, and those failing to meet, top tier evidence criteria.Results126 patients receiving MT from January 2012 to June 2015 were included (age 31–89 years, National Institutes of Health Stroke Scale (NIHSS) score 2–38); 62 (49%) patients would have been excluded if top tier criteria were upheld: pretreatment NIHSS score <6 (10%), Alberta Stroke Program Early CT score <6 (6.5%), premorbid modified Rankin Scale (mRS) score ≥2 (27%), M2 occlusion (10%), posterior circulation (32%), symptom to groin puncture >360 min (58%). 26 (42%) subjects had more than one top tier exclusion. Symptomatic intracerebral hemorrhage (sICH) and systemic hemorrhage rates were similar between the groups. 3 month mortality was 45% in those lacking top tier evidence compared with 26% (p=0.044), and 3 month mRS score 0–2 was 33% versus 46%, respectively (NS). After adjusting for potential confounders, top tier treatment was not associated with neurological improvement during hospitalization (β −8.2; 95% CI −24.6 to −8.2; p=0.321), 3 month mortality (OR=0.38; 95% CI 0.08 to 1.41), or 3 month favorable mRS (OR=0.97; 95% CI 0.28 to 3.35).ConclusionsOur study showed that with strict adherence to top tier evidence criteria, half of patients may not be considered for MT. Our data indicate no increased risk of sICH and a potentially higher mortality that is largely due to treatment of patients with basilar occlusions and those treated at an extended time window. Despite this, good functional recovery is possible, and consideration of MT in patients not meeting top tier evidence criteria may be warranted.

scholarly journals Stroke vision, aphasia, neglect (VAN) assessment—a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices

2016 ◽  
Vol 9 (2) ◽  
pp. 122-126 ◽  
Author(s):  
Mohamed S Teleb ◽  
Anna Ver Hage ◽  
Jaqueline Carter ◽  
Mahesh V Jayaraman ◽  
Ryan A McTaggart
Keyword(s):  
Pilot Study ◽  
Positive Predictive Value ◽  
Predictive Value ◽  
Screening Tool ◽  
Clinical Severity ◽  
Screening Tools ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Nihss Score

BackgroundIdentification of emergent large vessel occlusion (ELVO) stroke has become increasingly important with the recent publications of favorable acute stroke thrombectomy trials. Multiple screening tools exist but the length of the examination and the false positive rate range from good to adequate. A screening tool was designed and tested in the emergency department using nurse responders without a scoring system.MethodsThe vision, aphasia, and neglect (VAN) screening tool was designed to quickly assess functional neurovascular anatomy. While objective, there is no need to calculate or score with VAN. After training participating nurses to use it, VAN was used as an ELVO screen for all stroke patients on arrival to our emergency room before physician evaluation and CT scan.ResultsThere were 62 consecutive code stroke activations during the pilot study. 19 (31%) of the patients were VAN positive and 24 (39%) had a National Institutes of Health Stroke Scale (NIHSS) score of ≥6. All 14 patients with ELVO were either VAN positive or assigned a NIHSS score ≥6. While both clinical severity thresholds had 100% sensitivity, VAN was more specific (90% vs 74% for NIHSS ≥6). Similarly, while VAN and NIHSS ≥6 had 100% negative predictive value, VAN had a 74% positive predictive value while NIHSS ≥6 had only a 58% positive predictive value.ConclusionsThe VAN screening tool accurately identified ELVO patients and outperformed a NIHSS ≥6 severity threshold and may best allow clinical teams to expedite care and mobilize resources for ELVO patients. A larger study to both validate this screening tool and compare with others is warranted.

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.

Abstract P558: Identification of Embolic Stroke in Patients With Large Vessel Occlusion

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Lan Hong ◽  
Longting Lin ◽  
Gang Li ◽  
Jianhong Yang ◽  
Geng Yu ◽  
...  
Keyword(s):  
Perfusion Imaging ◽  
Delay Time ◽  
Validation Cohort ◽  
Embolic Stroke ◽  
Large Vessel ◽  
Smoking History ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Derivation Cohort ◽  
History Of

Objective: To develop a simple and objective score using clinical variables and quantified perfusion measures to identify embolic stroke with large vessel occlusions. Methods: Eligible patients from the Chinese centers participating in the International Stroke Perfusion Imaging Registry were included in this study. Patients were split into a derivation cohort (n=213) and a validation cohort (n=116). A score was developed according to the coefficients of independent predictors of embolic stroke from stepwise logistic regression model in the derivation cohort. The performance of the score was validated by assessing its discrimination and calibration. Additionally, a comparison between the area under curve (AUC) of history of atrial fibrillation (AF) alone and history of AF plus the score was also conducted. Results: The independent predictors of embolic stroke made up the Chinese Embolic Stroke Score (CHESS). There were: age (≥64 years, 1 point), non-smoking history (1 point), non-hypertension history (1 point) , baseline NIH Stroke Scale (≥14, 1 point) and delay time>6s volume/delay time>3s volume on perfusion imaging (≥0.23, 2 points). The AUC of CHESS in the derivation cohort and validation cohort were 0.80 and 0.72 respectively. Calibration tests indicated high agreement between predicted and observed probabilities. The AUC of AF-plus-CHESS compared to history of AF alone was significant (derivation cohort P<0.001; validation cohort P=0.01). Conclusions: In a Chinese population, CHESS reliably and independently identified embolic stroke as the cause of large vessel occlusion.

Abstract 3314: The Role of Bridging with Intravenous Thrombolysis in Endovascular Therapy of Acute Ischemic Stroke.

Stroke ◽  
2012 ◽  
Vol 43 (suppl_1) ◽  
Author(s):  
Omar Kass-Hout ◽  
Tareq Kass-Hout ◽  
Maxim Mokin ◽  
David Orion ◽  
Shadi Jahshan ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Endovascular Therapy ◽  
Combined Therapy ◽  
Large Vessel ◽  
P Value ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Nihss Score

Background: Large vessel occlusions with a high clot burden are less likely to improve with the FDA-approved IV strategy. Endovascular therapy within the first 3 h of stroke symptom onset provides an effective alternative treatment in patients with large vessel occlusion. It is not clear if combination of IV thrombolysis and endovascular approach is superior to endovascular treatment alone. Methods: We retrospectively reviewed all cases of acute ischemic stroke with large vessel occlusion treated within the first 3 h stroke onset during the 2005-2010 period. First group received endovascular therapy within the first 3 h of stroke onset. Second group consisted of patients who received IV thrombolysis within the first 3 h followed by endovascular therapy. We compared the following outcomes: revascularization rates, NIHSS score at discharge, mRS at discharge and 3months, symptomatic hemorrhage rates and mortality. Results: Among 104 patients identified, 42 received combined therapy, and 62 received endovascular therapy only. The two groups had similar demographic (age and sex distribution) and vascular risk factors distribution, as well as NIHSS score on admission (14.8±4.7 and 16.0±5.3; p=0.23). We found no difference in TIMI recanalization rates (Thrombolysis in Myocardial Infarction scale score of 2 or 3) following combined or endovascular therapy alone (83.3% and 79.0%; p=0.59). A preferred outcome, defined as a mRS of 2 or less at 90 days also did not differ between the combined therapy group and the endovascular only group (37.5% and 34.5%; p=0.76). There was no difference in mortality rate (22.5% and 31.0%; p=0.36) and the rate of symptomatic intracranial hemorrhage (9.5% and 8.1%; p=0.73). There was a significant difference in mean time from symptom onset to endovascular treatment between the combined group (227±88 min) and endovascular only group (125±40 min; p<0.0001).Patients with good TIMI recanalization rate of 2 or 3 showed a trend of having a better mRS at 90 days in both bridging (16.67% vs. 41.18%, p-value: 0.3813) and endovascular groups (25% vs. 34.78%, p-value: 0.7326).When analyzing the correlation of mRS at 90 days with the site of occlusion, patients in the bridging group showed a trend of a better outcome when the site of occlusion was ICA (33.3% vs 30%) and MCA (66.67% vs. 27.59%) and worse outcome when the site of occlusion was in the posterior circulation (26.32% vs. 50%), however, these results were not statistically significant (p-values: 0.1735& 0.5366). Conclusion: Combining IV thrombolysis and endovascular therapy achieves similar rates of clinical outcomes, revascularization rates, complications and mortality rates, when compared with endovascular treatment alone. The combined therapy, however, significantly delays initiation of endovascular treatment. A randomized prospective trial comparing both treatment strategies in acute ischemic stroke is warranted

Abstract TP77: Impact of Time and Aspects on Clinical Core Mismatch in Large Vessel Occlusion Strokes

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Shashvat Desai ◽  
Bradley J Molyneaux ◽  
Marcelo Rocha ◽  
Matthew Starr ◽  
Tudor G Jovin ◽  
...  
Keyword(s):  
Patient Selection ◽  
Time Window ◽  
Ct Perfusion ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Ct Head ◽  
Ischemic Core ◽  
The Impact ◽  
Core Volume

Introduction: Patient selection for endovascular thrombectomy (EVT) for anterior circulation large vessel occlusion (LVO) strokes in the 6-24-hour time window is dependent on delineating clinical core mismatch (CCM) as defined by DAWN trial criteria. In contrast, patient selection in the early window (0-6 hours) can be performed using ASPECTS on CT head. We aim to determine the prevalence of DAWN-CCM in LVO strokes and the impact of time and ASPECTS. Methods: Retrospective analysis of large vessel occlusion [internal carotid and middle cerebral artery-M1] strokes at a CSC. Consecutive patients who underwent CT perfusion or MRI within 120 minutes of CT head were included in the study (treated and untreated). Ischemic core volume was assessed using RAPID [IschemaView] and ASPECTS using automated ASPECTS [Brainomix]. CCM was defined using DAWN trial criteria [DAWN-CCM: NIHSS ≥10 and core <31 ml, NIHSS ≥20 and core <51 ml]. Results: A total of 116 patients were included. Mean age was 71 ±14 and 62% were females. Mean ischemic core volume and median ASPECTS were 46 ±65 ml and 8 (6-9), respectively. In patients with NIHSS score ≥10 (98), 57% had DAWN-CCM in the 0-24-hour window. Proportion of patients with DAWN-CCM in 6-24-hour window was 70% (6-12 hours), 50% (12-18 hours), and 50% (18-24 hours) [p=0.35]. Proportion of patients with DAWN-CCM by ASPECTS group was 88% (ASPECTS 9-10), 64% (ASPECTS 6-8) and 13% (ASPECTS 0-5) [p=<0.01] (Figure 1). Probability of DAWN-CCM declines by 7% for every 2 hours increase in TLKW to imaging, and by 13% for every 1-point decrease in ASPECTS. Conclusion: Approximately 57% of LVO strokes have clinical core mismatch. LVO strokes with DAWN-CCM decline with increasing time and decreasing ASPECTS. ASPECTS alone may be sufficient to identify patients with DAWN-CCM in a resource limited setting and avoid time consuming advanced imaging.

Presence of the hyperintense acute reperfusion marker on MRI after mechanical thrombectomy for large vessel occlusion is associated with worse early neurological recovery

2016 ◽  
Vol 9 (7) ◽  
pp. 641-643 ◽  
Author(s):  
Rishi Gupta ◽  
Chung-Huan Johnny Sun ◽  
Dustin Rochestie ◽  
Kumiko Owada ◽  
Ahmad Khaldi ◽  
...  
Keyword(s):  
Logistic Regression ◽  
Reperfusion Injury ◽  
Mechanical Thrombectomy ◽  
Binary Logistic Regression ◽  
Functional Independence ◽  
Large Vessel ◽  
Neurological Recovery ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Nihss Score

BackgroundMechanical thrombectomy has become the accepted treatment for large vessel occlusion in acute ischemic stroke. Unfortunately, a large cohort of patients do not achieve functional independence with treatment, even though the results are more robust than with medical management. The hyperintense acute reperfusion marker (HARM) on MRI is an indication of the breakdown of the blood–brain barrier and reperfusion injury.ObjectiveTo examine the hypothesis that the presence of HARM on MRI correlates with worse neurological recovery after reperfusion therapy.MethodsWe retrospectively reviewed 35 consecutive patients who between February 24, 2016 and April 23, 2016 underwent MRI to determine the presence of HARM after thrombectomy for anterior circulation large vessel occlusion. Demographic, radiographic imaging, and outcome data were collected. Univariate and binary logistic regression models were performed to assess predictors for improvement of the National Institutes of Health Stroke Scale (NIHSS) score by ≥8 points at 24 hours.ResultsThe 35 patients studied had an average age of 64±14 years of age with a median NIHSS score of 15 (IQR 9–20). Eighteen patients (51%) were found to have a HARM-positive MRI. In univariate analysis, patients with HARM were older, had lower reperfusion rates and more postprocedural hemorrhages. In binary logistic regression modeling, the absence of HARM was independently associated with a ≥8-point NIHSS score improvement at 24 hours (OR=7.14, 95% CI 1.22 to 41.67).ConclusionsThis preliminary analysis shows that the presence of HARM may be linked to worse neurological recovery 24 hours after thrombectomy. Reperfusion injury may affect the number of patients achieving functional independence after treatment.

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