Abstract P542: Management and Outcome of Stroke Patients With Tandem Carotid Occlusion in the ESCAPE NA1-Trial

Background: The optimal treatment for stroke patients with tandem cervical carotid occlusion is debated. We analyzed the treatment strategies and outcomes of tandem occlusion patients in the ESCAPE NA1 trial. Methods: ESCAPE NA1 was a multicenter international randomized trial of nerinetide vs. placebo in patients with acute ischemic stroke who underwent EVT. We defined tandem occlusions as complete occlusion of the cervical ICA on catheter angiography. The influence of tandem occlusions on outcome was analyzed using regression modeling with adjustment for age, sex, baseline NIHSS and ASPECTS, occlusion location, thrombolysis and treatment allocation. Results: 115 of 1105 patients (10.4%) had tandem occlusions. 73/115 tandem patients (66.0%) received treatment for the cervical occlusion: 21.9% were stented before thrombectomy, 68.5% were stented after thrombectomy, and 8.2% had angioplasty alone. Successful reperfusion was significantly higher in patients who had thrombectomy first followed by carotid treatment (eTICI 2b-3: 40/40 (100.0%)) or carotid angioplasty before and cervical stent after intracranial thrombectomy (9/10 (90.0%)) compared to carotid intervention before intracranial thrombectomy: (19/23 (82.1%), p=0.016). 90-day mRS 0-2 was achieved in 82/115 patients (71.3%) with tandem occlusions (treated occlusions: 74.0%, untreated: 66.7%) compared to 579/981 (59.5%) patients without tandem occlusions. In adjusted analysis, tandem occlusion was not predictive of outcome. In the subgroup of tandem patients, cervical stent-treatment was nominally associated with better outcomes (OR 2.2, 95% CI 0.5 - 9.2). Conclusion: Cervical carotid stenting may improve outcomes for EVT patients with tandem occlusions, but these results are limited by the sample size and non-randomized selection of patients for stenting.

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Abstract P355: Real-Word Performance of Two Automated Software Platforms for Identification of Salvageable Tissue in Stroke Patients: A Single Center Experience

Stroke ◽

10.1161/str.52.suppl_1.p355 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Angelos Katramados ◽

Horia Marin ◽

Maximilian Kole ◽

Owais Alsrouji ◽

Pala Varun ◽

...

Keyword(s):

Ct Perfusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Significant Discrepancy ◽

Endovascular Thrombectomy ◽

Stroke Treatment ◽

Software Platforms ◽

Automated Software ◽

Selection Of Patients ◽

Selection Of

Background and purpose: Modern stroke treatment has been revolutionized by image-guided selection of patients for endovascular thrombectomy. Current automated platforms allow for real-time identification of large vessel occlusion and salvageable brain tissue. We sought to evaluate the performance of these platforms with regard to identification of infarcted and salvageable tissue. Methods: We studied all patients that presented to Henry Ford Health System hospitals over a period of 6 weeks, received CT perfusion imaging of the brain upon initial presentation. The images were processed with two automated software platforms. We prospectively measured volumes of tissue with cerebral blood flow (CBF) < 30% of contralateral hemisphere, Tmax >6 secs, and hypoperfusion indices (defined as the ratio of volumes Tmax>10 secs and Tmax>6 secs). We compared the outputs of the two platforms and analyzed the performance of each platform. Results: 66 scans were included in our study. Both platforms were able to image all stroke patients within their FDA-approved indications. With regard to all scans, both platforms were noted to demonstrate comparable CBF<30% volumes (6.32 ml. vs 4.97 ml, p=0.276), and hypoperfusion indices (0.278 vs 0.338, p=0.344). However, there was statistically significant discrepancy in the volumes of tissue with Tmax>6 secs (23.96 vs 14.18 ml, p=0.023). Analysis of a subset of 12 scans, with evidence of LVO or severe symptomatic stenosis on corresponding CTA, showed again comparable CBF<30% volumes (12.84 ml vs 13.67 ml, p=0.725), and hypoperfusion indices (0.344 vs 0.314, p=0.699). However, the Tmax>6 secs volume discrepancy was greater and still statistically significant (75.54 ml vs 39.58 ml, p=0.048) Conclusions: Automated software platforms are an invaluable aid in the identification of salvageable tissue, and selection of patients for endovascular thrombectomy in the 6-24 hour window. However, the substantial difference in the identified volumes of hypoperfused tissue-at-risk may result in largely different clinical decisions and patient outcomes. Further validation efforts (and harmonization of algorithms) are required. Stroke teams should be aware of the limitations of automated analysis and need for expert review.

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Advanced neuroimaging in acute ischemic stroke: extending the time window for treatment

Neurosurgical FOCUS ◽

10.3171/2011.3.focus1146 ◽

2011 ◽

Vol 30 (6) ◽

pp. E5 ◽

Cited By ~ 3

Author(s):

E. Jesus Duffis ◽

Zaid Al-Qudah ◽

Charles J. Prestigiacomo ◽

Chirag Gandhi

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Perfusion Imaging ◽

Time Window ◽

Thrombolytic Treatment ◽

Stroke Patients ◽

Improved Outcomes ◽

Potential Applications ◽

Selection Of Patients ◽

Selection Of

Early treatment of ischemic stroke with thrombolytics is associated with improved outcomes, but few stroke patients receive thrombolytic treatment in part due to the 3-hour time window. Advances in neuroimaging may help to aid in the selection of patients who may still benefit from thrombolytic treatment beyond conventional time-based guidelines. In this article the authors review the available literature in support of using advanced neuroimaging to select patients for treatment beyond the 3-hour time window cutoff and explore potential applications and limitations of perfusion imaging in the treatment of acute ischemic stroke.

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Abstract WP19: Transfer Selection for Endovascular Therapy of Ischemic Stroke within A Collaborative Network: Off-site Versus On-site Neurology Service

Stroke ◽

10.1161/str.48.suppl_1.wp19 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Simon M Winzer ◽

Kristian Barlinn ◽

Johannes Gerber ◽

Timo Siepmann ◽

Lars-Peder Pallesen ◽

...

Keyword(s):

Ischemic Stroke ◽

Hospital Mortality ◽

Functional Outcome ◽

Endovascular Therapy ◽

Stroke Patients ◽

Anterior Circulation ◽

Comprehensive Stroke Center ◽

Favorable Functional Outcome ◽

Selection Of Patients ◽

Selection Of

Introduction: Selection of patients for endovascular therapy (EVT) may depend on the hospital providing first line assessment. In our collaborative stroke network, we aimed to compare clinical characteristics and outcomes in ischemic stroke patients undergoing EVT who were transferred from telestroke hospitals following teleconsultation and in those transferred from hospitals providing on-site neurology service. Methods: We analyzed prospectively collected data from consecutive ischemic stroke patients who underwent emergent EVT at our comprehensive stroke center (01/2010 to 12/2014) after acute transfer from either telestroke hospitals or non-telestroke hospitals with on-site neurology service. We compared baseline characteristics, onset-to-EVT time, symptomatic intracranial hemorrhage (sICH), favorable functional outcome (mRS 0-2) at discharge and in-hospital mortality. Results: Among 133 transferred patients who underwent emergent EVT: median age 67 years (IQR, 15); 56% men; median NIHSS score 17 (21); 52% had anterior and 48% posterior circulation stroke. Sixty-five patients (49%) were transferred from telestroke and 68 (51%) from non-telestroke hospitals. Telestroke patients were less severely affected (median NIHSS scores: 15 [7] vs. 22 [20]; p=.0005) and more likely to have anterior circulation stroke (69% vs. 35%; p<.0001) compared with non-telestroke patients. No between-group differences were present with regard to demographics, vascular risk factors, intravenous tPA rate and onset-to-EVT time. In-hospital mortality was lower among telestroke compared with non-telestroke patients (11% vs. 26%; p=.026). There were no differences in sICH (5% vs. 4%; p=1.0) and favorable functional outcome (17% vs. 18%; p=1.0). Conclusions: Patients transferred from telestroke hospitals were twice as often treated for anterior circulation stroke than those from non-telestroke neurological hospitals within our stroke network. This might be explained by more conservative selection of patients potentially amenable for EVT in hospitals harboring on-site neurology service but no EVT-capability. As our data was acquired prior to evidence from the positive EVT trials, further research is warranted to elaborate these findings.

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Risk Factors of Postprocedural Hypotension following Carotid Artery Stenting

Rivista di Neuroradiologia ◽

10.1177/197140099500800637 ◽

1995 ◽

Vol 8 (6) ◽

pp. 205-210

Author(s):

T. Nonaka ◽

S. Oka ◽

S. Miyata ◽

T. Baba ◽

T. Mikami ◽

...

Keyword(s):

Risk Factors ◽

Carotid Artery ◽

Clinical Characteristics ◽

Carotid Bifurcation ◽

Carotid Stenting ◽

Neurological Deficits ◽

Occurrence Rate ◽

Patients At Risk ◽

Selection Of Patients ◽

Selection Of

This study is performed to investigate risk factors of hypotension in response to elective carotid stenting. Forty-four lesions of 40 consecutive patients (mean age 70.4 ± 8.2 years) were retrospectively analyzed. Easy Wall stent was applied in 15 lesions and SMART stent in 29 lesions. We investigated correlations between the occurrence rate of postoperative hypotension below 90 mmHg and persisting over three hours and findings of preoperative angiograms, ultrasonograms and clinical characteristics. Postprocedural hypotension occurred in 19 patients (47.5%) and medical treatment (intravenous administration of catecholamines) was required in eleven patients (27.5%). Although there was no permanent neurological deficits related with postprocedural hypotension, transient neurological deficits were found in three patients. Risk factors of prolonged postprocedural hypotension were statistically analyzed. On angiographic characteristics; 1) distance between the carotid bifurcation and the lesion with maximum stenosis (≦10 mm vs. >10 mm: p = 0.031), 2) type of stenosis (eccentric vs. concentric: p = 0.014) On ultrasonographic characteristics; 1) calcifications at the carotid bifurcation (present vs. absent: p<0.001). Other variables, including age and degree of stenosis, were not associated with postprocedural hypotension after carotid stenting. These angiographic and ultrasonographic variables can be used to identify patients at risk for postprocedural hypotension after carotid stenting. Such identification may help in selection of patients who will benefit from appropriate pharmacological treatment.

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Identifying treatment responders using counterfactual modeling and potential outcomes

Statistical Methods in Medical Research ◽

10.1177/0962280218804569 ◽

2018 ◽

Vol 28 (10-11) ◽

pp. 3346-3362 ◽

Cited By ~ 2

Author(s):

Raphaël Porcher ◽

Justine Jacot ◽

Jay S Wunder ◽

David J Biau

Keyword(s):

Estimation Method ◽

Treatment Strategies ◽

Study Data ◽

Potential Outcomes ◽

Control Treatment ◽

Individual Treatment ◽

Right Censored Data ◽

Monotonicity Assumption ◽

Selection Of Patients ◽

Selection Of

Individualizing treatment according to patients' characteristics is central for personalized or precision medicine. There has been considerable recent research in developing statistical methods to determine optimal personalized treatment strategies by modeling the outcome of patients according to relevant covariates under each of the alternative treatments, and then relying on so-called predicted individual treatment effects. In this paper, we use potential outcomes and principal stratification frameworks and develop a multinomial model for left and right-censored data to estimate the probability that a patient is a responder given a set of baseline covariates. The model can apply to RCT or observational study data. This method is based on the monotonicity assumption, which implies that no patients would respond to the control treatment but not to the experimental one. We conduct a simulation study to evaluate the properties of the proposed estimation method. Results showed that the predictions of the probability of being a responder were well calibrated even if we observed variability and a small bias when many parameters were estimated. We finally applied the method to a cohort study on the selection of patients for additional radiotherapy after resection of a soft-tissue sarcoma.

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Risk Factors of Postprocedural Hypotension following Carotid Artery Stenting

Interventional Neuroradiology ◽

10.1177/15910199060120s137 ◽

2006 ◽

Vol 12 (1_suppl) ◽

pp. 205-210 ◽

Cited By ~ 3

Author(s):

T. Nonaka ◽

S. Oka ◽

S. Miyata ◽

T. Baba ◽

T. Mikami ◽

...

Keyword(s):

Risk Factors ◽

Carotid Artery ◽

Clinical Characteristics ◽

Carotid Bifurcation ◽

Carotid Stenting ◽

Neurological Deficits ◽

Occurrence Rate ◽

Patients At Risk ◽

Selection Of Patients ◽

Selection Of

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Abstract P377: Real-Word Performance of Two Automated Software Platforms for Large-Vessel Occlusion Identification in Acute Ischemic Stroke Patients: A Single Center Experience

Stroke ◽

10.1161/str.52.suppl_1.p377 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Angelos M Katramados ◽

Maximilian Kole ◽

Horia Marin ◽

Owais Alsrouji ◽

Pala Varun ◽

...

Keyword(s):

Large Vessel ◽

Test Accuracy ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Software Platforms ◽

Automated Software ◽

Selection Of Patients ◽

Selection Of

Background and purpose: Modern stroke treatment has been revolutionized by image-guided selection of patients for endovascular thrombectomy. Current automated platforms allow for real-time identification of large vessel occlusion and salvageable brain tissue. We had previously demonstrated that a “CTA for all” policy for stroke patients immediately upon arrival assists in the earlier identification of treatment candidates. We now sought to evaluate the performance of these platforms under this policy. Methods: All patients that presented to Henry Ford Health System hospitals over a period of 6 weeks received CTA of the head and neck upon initial presentation. The images were processed with two automated software platforms. We prospectively collected processing times, large-vessel-occlusion alerts, performance warnings, and LVO density ratios. We compared these with the interpretations of board-certified radiologists, and analyzed the performance of each platform. Results: 276 patients presented with stroke symptoms and received CT angiography upon presentation. Both platforms were able to image all stroke patients within their FDA-approved indications. Both platforms were noted to have comparable sensitivity, specificity, PPV and NPV, and excellent accuracy. The overall prevalence of LVO was extremely low (8/276). As a result, for both, NPV was much better than PPV because of the percentage of false positive results. Further ROC analysis, demonstrated an area under the ROC curve of 0.982, and overall model quality of 0.97. Optimal LVO density cutoff was <0.093 in order to maximize overall accuracy, or < 0.271, in order to maintain a sensitivity of 100% as an absolute priority (both significantly lower than the current threshold of <0.45). Conclusions: Automated software platforms are an invaluable aid in the selection of patients for endovascular thrombectomy. Different LVO detection algorithmic thresholds may be necessary (and should be part of individual stroke center validation pathways) to avoid fatigue alert, and optimize test accuracy, when LVO prevalence is low. Stroke teams should be aware of the limitations of automated analysis and need for expert review.

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