scholarly journals Leptomeningeal Collateral Flow Modifies Endovascular Treatment Efficacy on Large-Vessel Occlusion Strokes

Stroke ◽  
2021 ◽  
Vol 52 (1) ◽  
pp. 299-303
Author(s):  
Álvaro García-Tornel ◽  
Ludovico Ciolli ◽  
Marta Rubiera ◽  
Manuel Requena ◽  
Marian Muchada ◽  
...  
Keyword(s):  
Ct Angiography ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Multivariable Analysis ◽  
Large Vessel ◽  
Collateral Flow ◽  
Vessel Occlusion ◽  
Shift Analysis ◽  
Final Degree ◽  
Large Vessel Stroke

Background and Purpose: We aim to evaluate if good collateral flow (CF) modifies endovascular therapy (EVT) efficacy on large-vessel stroke. To do that, we used final degree of reperfusion and number of device-passes performed, factors previously associated with better functional outcome, as main outcome measures. Methods: Single-center retrospective study including consecutive stroke patients receiving EVT for anterior circulation large-vessel stroke. CF degree was assessed on CT angiography before EVT using a previously validated 4-grade score. Final degree of reperfusion, using modified Thrombolysis in Cerebral Ischemia (mTICI), and number of device-passes performed were prospectively collected. Multivariable analysis was performed to evaluate the influence of collateral flow degree on final degree of reperfusion and number of device-passes performed. Results: Six hundred twenty-six patients were included in the study; 369 patients (59%) presented good collateral flow on CT angiography. Five hundred twenty-two patients (84%) achieved successful reperfusion (mTICI 2B-3) after EVT, 304 (48%) of them with a final mTICI 2C-3. Median number of device-passes was 2 (interquartile range, 1–3). Good CF was independently associated with better final degree of reperfusion (shift analysis for mTICI0-2A/2B/2C-3%, poor CF 19/38/43 versus good CF 15/32/53, adjusted odds ratio, 1.51 [95% CI, 1.08–2.11]). Poor CF was independently associated with higher number of device-passes performed to achieve successful reperfusion (mTICI2B-3; shift analysis for 1/2/3/4+ device-passes, adjusted odds ratio, 1.59, [95% CI, 1.09–2.31]) and complete reperfusion (mTICI2C-3; shift analysis for 1/2/3/4+ device-passes, adjusted odds ratio, 1.70 [95% CI, 1.04–2.90]). Conclusions: Patients with good CF treated with EVT experience higher rates of successful reperfusion with lower number of device-passes. CF may facilitate thrombus retrieval and prevent distal embolization of clot fragments, improving device-passes efficacy.

scholarly journals Better Collaterals Are Independently Associated With Post-Thrombolysis Recanalization Before Thrombectomy

Stroke ◽  
2019 ◽  
Vol 50 (4) ◽  
pp. 867-872 ◽  
Author(s):  
Pierre Seners ◽  
Pauline Roca ◽  
Laurence Legrand ◽  
Guillaume Turc ◽  
Jean-Philippe Cottier ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Multivariable Analysis ◽  
Brain Magnetic Resonance Imaging ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Dynamic Susceptibility ◽  
Collateral Flow ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Perfusion Weighted Imaging

Background and Purpose— In acute stroke patients with large vessel occlusion, the goal of intravenous thrombolysis (IVT) is to achieve early recanalization (ER). Apart from occlusion site and thrombus length, predictors of early post-IVT recanalization are poorly known. Better collaterals might also facilitate ER, for instance, by improving delivery of the thrombolytic agent to both ends of the thrombus. In this proof-of-concept study, we tested the hypothesis that good collaterals independently predict post-IVT recanalization before thrombectomy. Methods— Patients from the registries of 6 French stroke centers with the following criteria were included: (1) acute stroke with large vessel occlusion treated with IVT and referred for thrombectomy between May 2015 and March 2017; (2) pre-IVT brain magnetic resonance imaging, including diffusion-weighted imaging, T2*, MR angiography, and dynamic susceptibility contrast perfusion-weighted imaging; and (3) ER evaluated ≤3 hours from IVT start on either first angiographic run or noninvasive imaging. A collateral flow map derived from perfusion-weighted imaging source data was automatically generated, replicating a previously validated method. Thrombus length was measured on T2*-based susceptibility vessel sign. Results— Of 224 eligible patients, 37 (16%) experienced ER. ER occurred in 10 of 83 (12%), 17 of 116 (15%), and 10 of 25 (40%) patients with poor/moderate, good, and excellent collaterals, respectively. In multivariable analysis, better collaterals were independently associated with ER ( P =0.029), together with shorter thrombus ( P <0.001) and more distal occlusion site ( P =0.010). Conclusions— In our sample of patients with stroke imaged with perfusion-weighted imaging before IVT and intended for thrombectomy, better collaterals were independently associated with post-IVT recanalization, supporting our hypothesis. These findings strengthen the idea that advanced imaging may play a key role for personalized medicine in identifying patients with large vessel occlusion most likely to benefit from IVT in the thrombectomy era.

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 A Prospective Study to Investigate Controlling Blood Pressure Under Transcranial Doppler After Endovascular Treatment in Patients With Occlusion of Anterior Circulation

2021 ◽  
Vol 12 ◽  
Author(s):  
Chunrong Tao ◽  
Pengfei Xu ◽  
Yang Yao ◽  
Yajuan Zhu ◽  
Rui Li ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Prospective Study ◽  
Transcranial Doppler ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
A Prospective Study

Objective: The objective of this study was to evaluate the effect of blood pressure (BP) management with transcranial Doppler (TCD) guidance in patients with large-vessel occlusion in the anterior circulation after endovascular thrombectomy (EVT) on the long-term prognosis.Methods: This was a prospective study; 232 patients were nonrandomized assigned to TCD-guided BP management (TBM) group or non-TCD-guided BP management (NBM) group. In the TBM group, BP was controlled according to TCD showing cerebral blood flow fluctuation. In the NBM group, BP was controlled according to the guidelines. The primary endpoint was a modified Rankin scale (mRS) score of 2 or lower at 90 days. The safety outcomes were the rates of symptomatic or any intracerebral hemorrhage (ICH) and mortality at 90 days.Results: One hundred sixty-three patients were assigned to the TBM group, and 69 were assigned to the NBM group. In the propensity score-matched cohort (65 matches in both groups), there was significant difference in the proportion of participants with mRS 0–2 at 90 days according to BP management (adjusted odds ratio 3.34, 95% CI 1.36 to 8.22). There was no difference in the rates of symptomatic or any ICH and mortality between two groups. In inverse probability-weighted regression adjustment analysis, mortality decreased significantly in the TBM group than in the NBM group (adjusted odds ratio 0.86, 95% CI 0.76–0.99, p = 0.03).Conclusion: In patients with acute ischemic stroke from large-vessel occlusion in the anterior circulation, BP management under TCD was superior to NBM in improving the clinical outcomes at 90 days.Clinical Trial Registration: (URL: https://www.chictr.org.cn/showproj.aspx?proj=55484; Identifier: ChiCTR2000034443.

scholarly journals Ischemic Core Overestimation on Computed Tomography Perfusion

Stroke ◽  
2021 ◽  
Author(s):  
Álvaro García-Tornel ◽  
Daniel Campos ◽  
Marta Rubiera ◽  
Sandra Boned ◽  
Marta Olivé-Gadea ◽  
...  
Keyword(s):  
Odds Ratio ◽  
Intensity Ratio ◽  
Adjusted Odds Ratio ◽  
Infarct Volume ◽  
Residue Function ◽  
Interquartile Range ◽  
Large Vessel ◽  
Imaging Time ◽  
Ischemic Core ◽  
Large Vessel Stroke

Background and Purpose: Different studies have pointed that CT perfusion (CTP) could overestimate ischemic core in early time window. We aim to evaluate the influence of time and collateral status on ischemic core overestimation. Methods: Retrospective single-center study including patients with anterior circulation large-vessel stroke that achieved reperfusion after endovascular treatment. Ischemic core and collateral status were automatically estimated on baseline CTP using commercially available software. CTP-derived core was considered as tissue with a relative reduction of cerebral blood flow <30%, as compared with contralateral hemisphere. Collateral status was assessed using the hypoperfusion intensity ratio (defined by the proportion of the time to maximum of tissue residue function >6 seconds with time to maximum of tissue residue function >10 seconds). Final infarct volume was measured on 24 to 48 hours noncontrast CT. Ischemic core overestimation was considered when CTP-derived core was larger than final infarct. Results: Four hundred and seven patients were included in the analysis. Median CTP-derived core and final infarct volume were 7 mL (interquartile range, 0–27) and 20 mL (interquartile range, 5–55), respectively. Median hypoperfusion intensity ratio was 0.46 (interquartile range, 0.23–0.59). Eighty-three patients (20%) presented ischemic core overestimation (median overestimation, 12 mL [interquartile range, 41–5]). Multivariable logistic regression analysis adjusted by CTP-derived core and confounding variables showed that poor collateral status (per 0.1 hypoperfusion intensity ratio increase; adjusted odds ratio, 1.41 [95% CI, 1.20–1.65]) and earlier onset to imaging time (per 60 minutes earlier; adjusted odds ratio, 1.14 [CI, 1.04–1.25]) were independently associated with core overestimation. No significant association was found with imaging to reperfusion time (per 30 minutes earlier; adjusted odds ratio, 1.17 [CI, 0.96–1.44]). Poor collateral status influence on core overestimation differed according to onset to imaging time, with a stronger size of effect on early imaging patients( P interaction <0.01). Conclusions: In patients with large-vessel stroke that achieve reperfusion after endovascular therapy, poor collateral status might induce higher rates of ischemic core overestimation on CTP, especially in patients in earlier window time. CTP reflects a hemodynamic state rather than tissue fate; collateral status and onset to imaging time are important factors to consider when estimating core on CTP.

Time-resolved assessment of collateral flow using 4D CT angiography in large-vessel occlusion stroke

2013 ◽  
Vol 24 (2) ◽  
pp. 390-396 ◽  
Author(s):  
Andreas M. J. Frölich ◽  
Sarah Lena Wolff ◽  
Marios N. Psychogios ◽  
Ernst Klotz ◽  
Ramona Schramm ◽  
...  
Keyword(s):  
Ct Angiography ◽  
Large Vessel ◽  
Collateral Flow ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Time Resolved ◽  
4D Ct

scholarly journals Early detection of large‐vessel occlusion stroke after cardiac surgery using CT angiography leading to early recanalization with endovascular thrombectomy

2021 ◽  
Vol 9 (5) ◽  
Author(s):  
Kiyoshi Takemoto ◽  
Masaaki Sakuraya ◽  
Michitaka Nakamura ◽  
Hidetsugu Maekawa ◽  
Kazuo Yamanaka ◽  
...  
Keyword(s):  
Cardiac Surgery ◽  
Early Detection ◽  
Ct Angiography ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy

scholarly journals Acute and Chronic Kidney Dysfunction and Outcome After Stroke Thrombectomy

2021 ◽  
Author(s):  
Simon Fandler-Höfler ◽  
Balazs Odler ◽  
Markus Kneihsl ◽  
Gerit Wünsch ◽  
Melanie Haidegger ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Mechanical Thrombectomy ◽  
Multivariable Analysis ◽  
Unfavorable Outcome ◽  
Large Vessel ◽  
Study Cohort ◽  
Large Vessel Occlusion ◽  
Kidney Dysfunction ◽  
Vessel Occlusion ◽  
The Impact

AbstractData on the impact of kidney dysfunction on outcome in patients with stroke due to large vessel occlusion are scarce. The few available studies are limited by only considering single kidney parameters measured at one time point. We thus investigated the influence of both chronic kidney disease (CKD) and acute kidney injury (AKI) on outcome after mechanical thrombectomy. We included consecutive patients with anterior circulation large vessel occlusion stroke receiving mechanical thrombectomy at our center over an 8-year period. We extracted clinical data from a prospective registry and investigated kidney serum parameters at admission, the following day and throughout hospital stay. CKD and AKI were defined according to established nephrological criteria. Unfavorable outcome was defined as scores of 3–6 on the modified Rankin Scale 3 months post-stroke. Among 465 patients, 31.8% had an impaired estimated glomerular filtration rate (eGFR) at admission (< 60 ml/min/1.73 m2). Impaired admission eGFR was related to unfavorable outcome in univariable analysis (p = 0.003), but not after multivariable adjustment (p = 0.96). Patients frequently met AKI criteria at admission (24.5%), which was associated with unfavorable outcome in a multivariable model (OR 3.03, 95% CI 1.73–5.30, p < 0.001). Moreover, patients who developed AKI during hospital stay also had a worse outcome (p = 0.002 in multivariable analysis). While CKD was not associated with 3-month outcome, we identified AKI either at admission or throughout the hospital stay as an independent predictor of unfavorable prognosis in this study cohort. This finding warrants further investigation of kidney–brain crosstalk in the setting of acute stroke.

Abstract 101: Predictors of Early Neurological Deterioration in Minor Strokes With Large Vessel Occlusion Treated With Intravenous Thrombolysis. A French Multicentric Observational Study (MINOR-STROKE)

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Pierre Seners ◽  
Claire Perrin ◽  
Guillaume Turc
Keyword(s):  
Basilar Artery ◽  
Multivariable Analysis ◽  
Intravenous Thrombolysis ◽  
Neurological Deterioration ◽  
Large Vessel ◽  
Minor Stroke ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Early Neurological Deterioration ◽  
Proximal Occlusion

Introduction: Whether thrombectomy added on intravenous thrombolysis (IVT), as compared to IVT alone, is beneficial in minor strokes with large vessel occlusion (LVO) is unknown. To identify predictors of early neurological deterioration (END) following IVT alone may help to select the best candidates for additional thrombectomy. Methods: MINOR-STROKE was a multicentric retrospective registry collecting data of IVT-treated minor strokes (NIHSS≤5) with LVO (internal carotid artery [ICA], M1, M2 or basilar artery; with central reading) treated with or without additional thrombectomy in 45 French stroke units. The patients initially intended for IVT alone, including those who eventually received thrombectomy due to END, were included in the present analysis. END was defined as a ≥4 points on NIHSS within 24hrs following admission. Thrombus length was measured centrally either on T2*-MRI, CT (hyperdense middle cerebral artery) or CT-angiography. Results: Overall, 799 patients were included: mean age 69 years, median NIHSS 3, occlusion located in ICA±M1/M2, proximal M1, distal M1, M2, or basilar artery in 20%, 7%, 19%, 50% and 4% of patients, respectively. Thrombus was visible in 78% of patients (median length 9mm, IQR 6-12mm). END occurred in 15% of patients and was associated with poor 3-month functional outcome (mRS>2: 55% vs. 12% of patients with and without END, respectively). Only 15% of ENDs were due to intracranial haemorrhage. In multivariable analysis, a more proximal occlusion site (M2 [reference], distal M1: OR 2.1 [IC95% 1.1-4.1], proximal M1: OR 3.8 [1.6-9.1], ICA±M1/M2: OR 5.0 [2.6-9.6], basilar artery: OR 4.9 [1.1-4.1]; P <0.001) and a longer thrombus (<6mm [reference], [6-9mm[: OR 1.3 [IC95% 0.6-2.9], [9-12mm[: OR 1.8 [0.8-3.9] and ≥12mm: OR 2.7 [1.3-5.6]; P =0.036) were independently associated with END. END occurred in 33%, 19%, 14%, 7% and 27% of patients with ICA±M1/M2, M1 proximal, M1 distal, M2 and basilar artery, respectively, and in 8%, 10%, 14% et 23% of patients with thrombus length of <6, [6-9[, [9-12[ and ≥12mm, respectively. Conclusion: Our study suggests that thrombus location and length are strong predictors of END in minor strokes with LVO. This may help to select the best candidates for additional endovascular therapy.

scholarly journals Relationships between brain perfusion and early recanalization after intravenous thrombolysis for acute stroke with large vessel occlusion

2019 ◽  
Vol 40 (3) ◽  
pp. 667-677 ◽  
Author(s):  
Pierre Seners ◽  
Guillaume Turc ◽  
Stéphanie Lion ◽  
Jean-Philippe Cottier ◽  
Tae-Hee Cho ◽  
...  
Keyword(s):  
Multivariable Analysis ◽  
Intravenous Thrombolysis ◽  
Brain Perfusion ◽  
Large Vessel ◽  
Dynamic Susceptibility ◽  
Large Vessel Occlusion ◽  
Dynamic Susceptibility Contrast ◽  
Infarct Core ◽  
Vessel Occlusion ◽  
Susceptibility Contrast

In large vessel occlusion (LVO) stroke, it is unclear whether severity of ischemia is involved in early post-thrombolysis recanalization over and above thrombus site and length. Here we assessed the relationships between perfusion parameters and early recanalization following intravenous thrombolysis administration in LVO patients. From a multicenter registry, we identified 218 thrombolysed LVO patients referred for thrombectomy with both (i) pre-thrombolysis MRI, including diffusion-weighted imaging (DWI), T2*-imaging, MR-angiography and dynamic susceptibility-contrast perfusion-weighted imaging (PWI); and (ii) evaluation of recanalization on first angiographic run or non-invasive imaging ≤ 3 h from thrombolysis start. Infarct core volume on DWI, PWI-DWI mismatch volume and hypoperfusion intensity ratio (HIR; defined as Tmax ≥ 10 s volume/ Tmax ≥ 6 s volume, low HIR indicating milder hypoperfusion) were determined using a commercially available software. Early recanalization occurred in 34 (16%) patients, and multivariable analysis was associated with lower HIR ( P = 0.006), shorter thrombus on T2*-imaging ( P < 0.001) and more distal occlusion ( P = 0.006). However, the relationship between HIR and early recanalization was robust only for thrombus length <14 mm. In summary, the present study disclosed an association between lower HIR and early post-thrombolysis recanalization. Early post-thrombolysis recanalization is therefore determined not only by thrombus site and length but also by severity of ischemia.

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