scholarly journals Prevalence and Temporal Distribution of Fast and Slow Progressors of Infarct Growth in Large Vessel Occlusion Stroke

Stroke ◽  
2019 ◽  
Vol 50 (8) ◽  
pp. 2238-2240 ◽  
Author(s):  
Marcelo Rocha ◽  
Shashvat M. Desai ◽  
Ashutosh P. Jadhav ◽  
Tudor G. Jovin
Keyword(s):  
Temporal Distribution ◽  
Stroke Onset ◽  
Large Vessel ◽  
Delayed Presentation ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Slow Progressors ◽  
Ischemic Core ◽  
Core Volume

Background and Purpose— Fast and slow progressors of infarct growth due to anterior circulation large vessel occlusion are commonly observed in clinical practice. We aimed to estimate the prevalence and temporal distribution of fast and slow progressors among anterior circulation large vessel occlusion patients diagnosed within 24 hours of stroke onset. Methods— Single-center retrospective study of all patients with anterior circulation large vessel occlusion who underwent baseline computed tomographic perfusion or magnetic resonance imaging within 24 hours of stroke onset. Prevalence was determined for fast progressors (ischemic core >70 mL, <6 hours of stroke onset) and slow progressors (ischemic core ≤30 mL, >6–24 hours of stroke onset). Results— One hundred eighty-five patients were included. The median time interval from stroke onset to baseline core imaging was 7.6 hours (interquartile range, 3.9–13.2), and median core volume was 17 mL (range, 0–405). Patients had core volume ≤70 mL in 72% of cases in the overall cohort. The prevalence of fast progressors was 25% (95% CI, 17%–37%) and reached 40% (95% CI, 24%–59%) between 3 and 4.5 hours after stroke onset. The prevalence of slow progressors was 55% (95% CI, 46%–64%) and was similar across time intervals beyond 6 hours after stroke onset. Conclusions— Most anterior circulation large vessel occlusion patients had small-to-moderate ischemic core volume, irrespective of early or delayed presentation within 24 hours of stroke onset. Fast progressors were highly prevalent between 3 and 4.5 hours after stroke onset.

Abstract WP163: Clinical Characteristics of Fast and Slow Progressors of Infarct Growth Due to Anterior Circulation Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Marcelo Rocha ◽  
Shashvat Desai ◽  
Tudor Jovin ◽  
Ashutosh Jadhav
Keyword(s):  
Stroke Onset ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Slow Progressors ◽  
Mca Occlusion ◽  
Tandem Occlusion ◽  
Slow Progression ◽  
Ischemic Core

Background and Purpose: Inter-individual variability of fast to slow progression of early infarct growth in anterior circulation large vessel occlusion (ACLVO) stroke has been previously well quantified. However, the underlying pathophysiology of these clinical phenotypes remains poorly understood. We aimed to determine clinical and radiographic variables associated with fast or slow progressor phenotypes of ACLVO stroke. Methods: Single-center retrospective study of all patients with intracranial ICA or MCA occlusion, with or without tandem cervical ICA occlusion, who underwent baseline advanced imaging including CTP or MRI within 24 hours of stroke onset. Fast progressors (ischemic core > 70 ml, < 6 hours of stroke onset) and slow progressors (ischemic core ≤ 30 ml, > 6 to 24 hours of stroke onset) were identified. Demographics, co-morbidities, admission NIHSS and ACLVO type were tested in univariate and multivariate analysis for association with fast or slow progressor status. Results: A total of 185 patients were included with mean age 71 ± 15 and NIHSS 17 ± 7; 60% were female. Patients had occlusion of the MCA in 72% or the intracranial ICA in 28% of cases. Of these, 20% had a tandem cervical ICA occlusion. In the early epoch, there were no significant differences in age, sex, NIHSS, co-morbidities or ACLVO type between fast progressors (n=19) versus controls (n=56). In the delayed epoch, the mean NIHSS was 14±6 in slow progressors (n=61) versus 19±7 in controls (n=49). Slow progressors had MCA occlusion in 80% versus 63% (p < 0.05) and tandem occlusion in 10% versus 35% of controls (p < 0.01). In multivariate logistic regression modeling, age (OR 1.04, 95% CI 1.01-1.07) and NIHSS (OR 0.87, 95% CI 0.81-0.93) but not ACLVO types were independently associated with slow progressor status. Conclusions: Although greater frequency of MCA occlusion and absence of tandem cervical ICA occlusion were prevalent amongst slow progressors, only age and NIHSS were independent predictors. Future studies are needed to better characterize the underlying clinical substrates for fast versus slow progression of ACLVO stroke.

Clinical characteristics of fast and slow progressors of infarct growth in anterior circulation large vessel occlusion stroke

2021 ◽  
pp. 0271678X2110150
Author(s):  
Marcelo Rocha ◽  
Shashvat Desai ◽  
Jiyeon Son ◽  
Daniel A Tonetti ◽  
Tudor Jovin ◽  
...  
Keyword(s):  
Hemoglobin Concentration ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Clinical Predictors ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Mild Anemia ◽  
Slow Progressors ◽  
History Of ◽  
Ischemic Core

Fast and slow progressor phenotypes of infarct growth due to anterior circulation large vessel occlusion (ACLVO) remain poorly understood. We aimed to define clinical predictors of fast and slow progressors in a retrospective study of patients with ACLVO who underwent baseline advanced imaging within 24 hours of stroke onset. Fast progressors (ischemic core > 70 ml, < 6 hours after onset) and slow progressors (ischemic core ≤ 30 ml, 6 to 24 hours after onset) were identified amongst 185 patients. Clinical and laboratory variables were tested for association with fast or slow progressor status. In the early epoch, no significant differences were found between fast progressors and controls. In the delayed epoch, slow progressors had a median NIHSS of 14 versus 20 (p < 0.01) and MCA occlusion in 80% versus 63% (p < 0.05) relative to controls. In multivariate analyses, NIHSS (OR 0.83, 95% CI 0.73-0.95), hyperlipidemia (OR 4.24, 95% CI 1.01 – 19.3) and hemoglobin concentration (OR 0.75, 95% CI 0.57 – 0.99) were independently associated with slow progressor status. This study indicates that lower initial stroke symptom severity, a history of hyperlipidemia and mild anemia are associated with individual tolerance to ACLVO stroke.

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.

Abstract TP81: A Closer Look at MRI-Based Core in Patients With Large Vessel Occlusion Within 6 Hours From Onset

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Marie Luby ◽  
Yojan Shah ◽  
Evan McCreedy ◽  
Kyle Kern ◽  
Lawrence L Latour ◽  
...  
Keyword(s):  
Onset Time ◽  
Large Vessel ◽  
Mri Imaging ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Neurological Improvement ◽  
Stroke Study ◽  
Treatment Onset ◽  
Core Volume

Introduction: Recent clinical trials including EXTEND-IA and SWIFT PRIME utilized CT and MRI imaging to exclude large core patients from endovascular therapy (EVT) presenting within 6 hours from onset. We hypothesize that patients with clinical-core mismatch, retrospectively defined as admit NIHSS ≥ 6 and core volume ≤20 mL, were more likely to have early neurological improvement versus those who did not. Methods: Patients included had confirmed large vessel occlusion in the anterior circulation, presented within 6 hours from last known normal, were screened pre-EVT with multimodal MRI, treated with EVT between January 2015 through July 2019, and consented to Natural History of Stroke Study. Core volumes were calculated using a fully automated algorithm, “coretool”, based on processed DWI and ADC maps thresholded at ≤620 μm 2 /sec. Perfusion deficit volumes were calculated by thresholding Tmax maps at >6 sec delay. Early neurological improvement (ENI) was defined as a decrease in NIHSS≥8 points or NIHSS of 0-1 at 24 hours. Results: Fifty-four patients met study criteria with median age 54 years, 59% female, admit NIHSS=19 [13-23], onset=117 min [59-155], onset to groin=212 min [171-265], core volume=9mL [4-31], Tmax volume=82mL [50-107], mismatch volume=51mL [30-86], mismatch ratio=7.5 [2.6-11.9], and 90 day mRS=3 [1-5]. Of the 54 patients, 61% (n=33) had clinical-core mismatch while 39% (n=21) did not. Patients with mismatch had smaller core volumes, median 6 versus 39mL (p<0.001) and larger mismatch ratios, median 8.9 versus 2.6, (p=0.003), but no differences in age, sex, IV tPA treatment, onset time, onset to groin time, admit NIHSS, complete recanalization rate, Tmax volume, mismatch volume, or day 90 mRS. Fifty-five percent (18/33) of patients with clinical-core mismatch had ENI at 24 hours versus 24% (5/21) without (p=0.026). Conclusions: Patients with clinical-core mismatch had a significantly higher rate of early neurological improvement at 24 hours post EVT. However, some patients without mismatch but with complete recanalization still did well. Alternative definitions of mismatch, outside of current guidelines, may identify patients that will benefit more from EVT.

scholarly journals Decomposing Acute Symptom Severity in Large Vessel Occlusion Stroke: Association With Multiparametric CT Imaging and Clinical Parameters

2021 ◽  
Vol 12 ◽  
Author(s):  
Lena Stueckelschweiger ◽  
Steffen Tiedt ◽  
Daniel Puhr-Westerheide ◽  
Matthias P. Fabritius ◽  
Franziska Mueller ◽  
...  
Keyword(s):  
Symptom Severity ◽  
Large Vessel ◽  
Clinical Parameters ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Acute Symptom ◽  
Imaging Parameters ◽  
Clot Burden ◽  
Ischemic Core ◽  
Core Volume

Background and Purpose: Acute ischemic stroke of the anterior circulation due to large vessel occlusion (LVO) is a multifactorial process, which causes neurologic symptoms of different degree. Our aim was to examine the impact of neuromorphologic and vascular correlates as well as clinical factors on acute symptom severity in LVO stroke.Methods: We selected LVO stroke patients with known onset time from a consecutive cohort which underwent multiparametric CT including non-contrast CT, CT angiography and CT perfusion (CTP) before thrombectomy. Software-based quantification was used to calculate CTP total ischemic and ischemic core volume. Symptom severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) upon admission. Multivariable regression analysis was performed to determine independent associations of admission NIHSS with imaging and clinical parameters. Receiver operating characteristics (ROC) analyses were used to examine performance of imaging parameters to classify symptom severity.Results: We included 142 patients. Linear and ordinal regression analyses for NIHSS and NIHSS severity groups identified significant associations for total ischemic volume [β = 0.31, p = 0.01; Odds ratio (OR) = 1.11, 95%-confidence-interval (CI): 1.02–1.19], clot burden score (β = −0.28, p = 0.01; OR = 0.76, 95%-CI: 0.64–0.90) and age (β = 0.17, p = 0.04). No association was found for ischemic core volume, stroke side, collaterals and time from onset. Stroke topography according to the Alberta Stroke Program CT Score template did not display significant influence after correction for multiple comparisons. AUC for classification of the NIHSS threshold ≥6 by total ischemic volume was 0.81 (p &lt; 0.001).Conclusions: We determined total ischemic volume, clot burden and age as relevant drivers for baseline NIHSS in acute LVO stroke. This suggests that not only mere volume but also degree of occlusion influences symptom severity. Use of imaging parameters as surrogate for baseline NIHSS reached limited performance underlining the need for combined clinical and imaging assessment in acute stroke management.

Abstract TP78: Classification of Ischemic Core Distribution Pattern Using Computed Tomography Perfusion in Anterior Circulation Acute Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Takumi Morita ◽  
Ryota Ishibashi ◽  
Hiroyuki Yamamoto ◽  
Toshio Fujiwara ◽  
Ryosuke Kaneko ◽  
...  
Keyword(s):  
Distribution Pattern ◽  
Univariate Analysis ◽  
Large Vessel ◽  
Type B ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
Outcome Group ◽  
Ischemic Core

Introduction: The evaluation of ischemic core is important in acute cerebral infarction with large vessel occlusion. The ischemic core is thought to approximate the region that is difficult to receive collateral circulation. We classified the ischemic core distribution pattern into four types on the basis of the tendency of cerebral blood volume (CBV) decrease in the ischemic core, and examined the prognostic ability. Methods: We included M1 or ICA occlusion which completely recanalized (TICI3) by thrombectomy in our institute from January 2015 to May 2019. The ischemic core was defined as a region where CBV were reduced less than 1.9 ml/100cc. Ischemic core distribution pattern was classified into the following 4 types. Type A: absent of ischemic core. Type B: ischemic core is confined to the basal ganglia and white matter. Type C1: ischemic core is present in the cortex but less than half of MCA region. Type C2: ischemic core is present in the cortex, and more than half of MCA region. The patient characteristics, temporal parameters, ASPECTS and ischemic core distribution pattern were analyzed with mRS0-2 at discharge as a good outcome group. Results: A total of 47 cases (14 ICA, 33 M1) were included. Ischemic core distribution pattern correlated well with mRS at discharge (p<0.004). Factors that showed a significance in univariate analysis between the good outcome group (n=19) and the poor outcome group (n=28) were age (76 vs 80.5, p=0.037), ASPECTS (10 vs 9, p=0.027), ischemic core distribution type (B vs C1, p=0.002), last known well to recanalization time (191 vs 272.5, p=0.027). Among these factors, multivariate analysis correlated significantly with age (OR, 1.18; 95CI,1.01-1.36), ischemic core distribution pattern (OR, 5.01; 95CI, 1.8-13.9), and recanalization time (OR, 1.46; 95CI, 1.01-2.12). Conclusions: The distribution pattern of ischemic core defined by reduced CBV have good correlation with outcome. There is a possibility that it can be used as a simple tool to predict prognosis using CT perfusion in anterior circulation acute large vessel occlusion.

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