scholarly journals Physiologic predictors of collateral circulation and infarct growth during anesthesia – Detailed analyses of the GOLIATH trial

2019 ◽  
Vol 40 (6) ◽  
pp. 1203-1212 ◽  
Author(s):  
Radoslav Raychev ◽  
David S Liebeskind ◽  
Albert J Yoo ◽  
Mads Rasmussen ◽  
Dimiter Arnaudov ◽  
...  
Keyword(s):  
Collateral Circulation ◽  
Infarct Volume ◽  
Strong Predictor ◽  
Multivariable Analysis ◽  
Vessel Occlusion ◽  
Volume Estimate ◽  
Induced Hypotension ◽  
Pressor Therapy ◽  
Grading Scale ◽  
Multiple Variables

Collateral circulation plays a pivotal role in acute ischemic stroke due to large vessel occlusion (LVO) and may be affected by multiple variables during sedation for endovascular therapy (EVT). We conducted detailed analyses of the GOLIATH trial to identify predictors of collateral circulation grade and infarct growth. We also modified the ASITN collateral grading scale and sought to determine its impact on clinical outcome and infarct growth. Multivariable analysis was used to identify predictors of collaterals and infarct growth. Ordinal analysis demonstrated nominal, but non-significant association between modified ASITN scale and infarct growth. Among all analyzed baseline clinical and procedural variables, the most significant predictors of infarct growth at 24 h were phenylephrine dose (estimate 6.78; p = 0.014) and baseline infarct volume (estimate 0.93; p = 0.03). The most significant predictors of worse collateral grade were mean arterial pressure (MAP) <70 mmHg (OR 0.35; p = 0.048) and baseline infarct volume (OR 0.96; p = 0.003). Hypotension during sedation for EVT for LVO negatively impacts collateral circulation, while higher pressor dose is a strong predictor of infarct growth. Avoidance of anesthesia-induced hypotension and consequent need for pressor therapy may prevent collateral failure and minimize infarct growth.

Abstract P485: Predictors and Clinical Impact of Deep Grey Matter Infarction After Endovascular Treatment for Large Vessel Occlusion Stroke: Results From the Escape-NA1 Trial

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Johanna Ospel ◽  
Michael D Hill ◽  
Nima Kashani ◽  
Arnuv Mayank ◽  
Nishita Singh ◽  
...  
Keyword(s):  
Grey Matter ◽  
Infarct Volume ◽  
Multivariable Analysis ◽  
Diffusion Weighted Mri ◽  
Vessel Occlusion ◽  
Lentiform Nucleus ◽  
Good Outcome ◽  
Deep Grey Matter ◽  
Post Hoc

Purpose: In this post-hoc analysis of the ESCAPE-NA1 trial, we investigated the prevalence of deep grey matter infarcts and their influence on clinical outcome. Methods: Infarcts on 24 hour follow up imaging (non contrast head CT or diffusion-weighted MRI) were categorized as predominantly deep grey matter infarcts (caudate and/or lentiform nucleus infarcts with sparing of the superficial grey matter and white matter) vs. other infarcts. Total infarct volume was manually segmented in all patients. When MRI follow-up was available, deep grey matter and grey matter infarct volumes were segmented separately. Multivariable logistic regression with adjustment for key minimization variables and by infarct volume was used to assess the association of predominantly deep grey matter infarcts and good outcome. Results: Of the 1026 included patients, 316 (30.8%) had predominantly deep grey matter infarcts. Cumulative proportions of good outcome for overall, grey matter, deep grey matter, and superficial grey matter infarct volumes are shown in the figure. Good outcomes were more frequently achieved in patients with predominantly deep grey matter infarcts (239/316 [75.6%] vs. 374/704 [53.1%]). Deep infarcts were tightly correlated with infarct volume (Pearson rho -0.35) and in multivariable analysis deep grey matter infarcts were predictive of outcome overall; when examined in volume percentiles, there was no effect of deep infarct location. Conclusion: Predominantly deep grey matter infarcts are associated with good outcomes. Deep grey matter infarct location favorable prognosis is associated with small overall infarct size.

Abstract WP367: Effect of Early Blood Pressure Reduction on Infarct Size in Patients With Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
David Baker ◽  
Dinesh Jillella ◽  
Takashi Shimoyama ◽  
Ken Uchino
Keyword(s):  
Magnetic Resonance Imaging ◽  
Blood Pressure ◽  
Infarct Size ◽  
Collateral Circulation ◽  
Infarct Volume ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Resonance Imaging ◽  
Vessel Occlusion ◽  
Significant Drop

Introduction: In patients with large vessel occlusion presenting with acute ischemic stroke, cerebral perfusion is a major determinant of stroke severity. However, limited data exists to guide hemodynamic management of these patients early after presentation. In this study, we aim to evaluate the effect of blood pressure reductions during the hyper-acute period on infarct size. Methods: From a clinical stroke registry at a single comprehensive stroke center, we reviewed patients with middle cerebral artery (M1) or internal carotid artery occlusion who underwent hyperacute magnetic resonance imaging (MRI) for endovascular treatment decision in 2018. Infarct volume was determined by area of reduced apparent diffusion coefficient using RAPID software. Collateral circulation was scored based on baseline CT angiogram (good collaterals constituted >50% filling, poor collaterals ≤50% filling). Average mean arterial pressure (MAP) readings from the first hour of presentation were compared to average MAP readings from the hour prior to magnetic resonance imaging. For the purposes of our study, a drop of > 20% in the average MAP was regarded as a significant decrease. We hypothesized that both significant drop in MAP and the presence of good collateral circulation were independent predictors of infarct volume expressed as a logarithmic value in multivariable regression model. Results: Of the 35 patients (mean age 67, mean NIHSS 16) meeting inclusion criteria, 11% of patients experienced an early significant drop in MAP prior to time of MRI. Among patients with a significant drop in MAP, the average decrease was 35 mm Hg ±3.3 among those with significant drop from a baseline mean MAP of 125 mm Hg. In the multivariable analysis adjusting for collateral status, a significant drop in average MAP was independently associated with an increase in infarct volume (β = -0.727, p=0.0306). Collateral status also independently predicted infarct size (β=0.775, p=0.0007). Conclusion: Among ischemic stroke patients with large vessel occlusion, a >20% drop in MAP during the hyper-acute period is associated with larger infarct volumes. Further studies are needed to optimize early blood pressure management in these patients.

scholarly journals Qualitative Posttreatment Diffusion-Weighted Imaging as a Predictor of 90-day Outcome in Stroke Intervention

2019 ◽  
Vol 47 (2) ◽  
pp. 160-166
Author(s):  
Adam A Dmytriw ◽  
Abdullah Alrashed ◽  
Alejandro Enriquez-Marulanda ◽  
Shadi Daghighi ◽  
Ghouth Waggas ◽  
...  
Keyword(s):  
Diffusion Weighted Imaging ◽  
Infarct Volume ◽  
Multivariable Analysis ◽  
Poor Performance ◽  
Recombinant Tissue Plasminogen Activator ◽  
National Institutes Of Health ◽  
Infarct Core ◽  
Vessel Occlusion ◽  
Subjective Impression ◽  
Diffusion Weighted

ABSTRACT:Purpose:The aim was to assess the ability of post-treatment diffusion-weighted imaging (DWI) to predict 90-day functional outcome in patients with endovascular therapy (EVT) for large vessel occlusion in acute ischemic stroke (AIS).Methods:We examined a retrospective cohort from March 2016 to January 2018, of consecutive patients with AIS who received EVT. Planimetric DWI was obtained and infarct volume calculated. Four blinded readers were asked to predict modified Rankin Score (mRS) at 90 days post-thrombectomy.Results:Fifty-one patients received endovascular treatment (mean age 65.1 years, median National Institutes of Health Stroke Scale (NIHSS) 18). Mean infarct volume was 43.7 mL. The baseline NIHSS, 24-hour NIHSS, and the DWI volume were lower for the mRS 0–2 group. Also, the thrombolysis in cerebral infarction (TICI) 2b/3 rate was higher in the mRS 0–2 group. No differences were found in terms of the occlusion level, reperfusion technique, or recombinant tissue plasminogen activator use. There was a significant association noted between average infarct volume and mRS at 90 days. On multivariable analysis, higher infarct volume was significantly associated with 90-day mRS 3–5 when adjusted to TICI scores and occlusion location (OR 1.01; CI 95% 1.001–1.03; p = 0.008). Area under curve analysis showed poor performance of DWI volume reader ability to qualitatively predict 90-day mRS.Conclusion:The subjective impression of DWI as a predictor of clinical outcome is poorly correlated when controlling for premorbid status and other confounders. Qualitative DWI by experienced readers both overestimated the severity of stroke for patients who achieved good recovery and underestimated the mRS for poor outcome patients. Infarct core quantitation was reliable.

Abstract WP40: “Good” Angiographic Collateral Circulation Correlates With Lower Dwi Infarct Volumes In Acute Ischemic Stroke

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Esteban Cheng-Ching ◽  
Dolora Wisco ◽  
Shumei Man ◽  
Ferdinand Hui ◽  
Gabor Toth ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Symptom Onset ◽  
Collateral Circulation ◽  
Infarct Volume ◽  
Artery Occlusion ◽  
Grading System ◽  
Large Artery ◽  
Anterior Circulation ◽  
Vessel Occlusion

Background and purpose Large artery occlusion leads to ischemic stroke which volume is influenced by time from symptom onset. This effect is modulated by several factors, including the presence and degree of collateral circulation. We analyze the correlation between a standard angiographic collateral grading system and DWI infarct volumes. Methods We reviewed a prospectively collected retrospective database of ischemic stroke patients admitted between august of 2006 and december of 2011. We included patients with anterior circulation acute ischemic stroke presenting within 8 hours from symptom onset with large vessel occlusion, who underwent pre-treatment MRI and endovascular therapy. DWI infarct volumes were measured by region of interest. ASITN collateral grading system was used and grouped into “good collaterals” for grades 3 and 4, and “poor collaterals” for grades 0, 1 and 2. JMP statistical software was utilized. Results 152 patients (71 (46.7%) male, mean age: 68±15 years;) were included in the initial analysis. We identified 49 patients who had angiographic collateral circulation grading. Seven patients had ASITN collateral grade 0 with mean infarct volume of 27.6 cc, 25 had collateral grade of 1 with mean infarct volume of 27.9 cc, 10 had collateral grade of 2 with mean infarct volume of 23.4 cc, 5 had collateral grade of 3 with mean infarct volume of 6.3 cc, and 2 had collateral grade of 4 with mean infarct volume of 14.6 cc. Forty two patients had “poor collaterals” with a mean infarct volume of 26.8 cc. Seven patients had “good collaterals” with mean infarct volume of 8.7 cc. When comparing the infarct volumes between these two groups, the difference was statistically significant (p=0.017). Conclusions In anterior circulation acute ischemic stroke, “good” angiographic collateral circulation defined as ASITN grading system of 3 or 4, correlates with lower infarct volumes on presentation.

Abstract WP58: Correlating Stroke Volume with National Institute of Health Stroke Scale as a Means of Determining Patient Prognosis

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Pamela J Zelnick ◽  
Liang Zhu ◽  
Louise D McCullough ◽  
Amrou Sarraj
Keyword(s):  
Patient Outcomes ◽  
Infarct Volume ◽  
Strong Predictor ◽  
Ratio Test ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
Poor Outcome ◽  
The Poor ◽  
Poor Outcome Group ◽  
Outcome Group

Introduction: The NIH Stroke Scale (SS) is a widely used tool for directing treatment and predicting outcomes in Acute Ischemic Stroke (AIS). Severe strokes with high admission SS often correlate with long term disability, and as such, SS serves as a strong predictor of outcome. Final infarct volume (FIV) is also a pivotal predictor of stroke outcome. We aimed to evaluate the relationship between SS, FIV and outcome, and hypothesize that a combined approach evaluating both FIV and SS may more accurately correlate with patient outcomes. Methods: A single center, retrospective cohort study, examined AIS patients with large vessel occlusion (LVO) affecting the anterior circulation, between July 2004 and April 2013. Patients were stratified by treatment to 1) intra-arterial therapy, 2) IV tPA, 3) both or 4) neither. Primary outcomes measured were mRS at discharge and 90 days (good outcome mRS 0-2, poor 4-6). FIV was manually calculated from DWI obtained within the first 7 days of presentation. SS and FIV were compared against good and poor mRS outcomes using Wilcoxon rank sum test. Logistic regression analysis was used to evaluate the association between SS, FIV and mRS. Finally, likelihood ratio test was used to compare model fit between a model including SS alone and model including both SS and FIV. Results: In 332 patients, SS was significantly higher in the poor outcome group (17.3 ± 5.4) when compared to the good outcome group (13.0 ± 6.1) (p=0.0002). In the same analysis, FIVs were also larger in the poor outcome group (110.3 ± 113 cm3) when compared to the good outcome group (37.2 ± 68.3 cm3) (p<0.0001). A combined SS and FIV model correlated significantly better with discharge outcome than did SS alone (p=0.0015). Analysis of 182 patient outcomes at 90 days maintained similar findings, with SS (18 ± 5.9) and FIVs (115.4 ± 121.0 cm3) significantly higher in poor outcomes than in good outcomes; (13.0 ± 5.4) and (35.7 ± 38.2 cm3) respectively (p<0.0001). Combined SS and FIV model, again, was significantly better at modeling outcome at 90 days than was a model including SS alone (p=0.0044). Conclusions: A combined model including FIV and SS better correlates with clinical outcomes at discharge and 90 days in patients with AIS due to LVO, than does a model using SS alone.

Endovascular reperfusion outcomes in patients with a stroke and low ASPECTS is highly dependent on baseline infarct volumes

2021 ◽  
pp. neurintsurg-2020-017184
Author(s):  
Mehdi Bouslama ◽  
Clara M Barreira ◽  
Diogo C Haussen ◽  
Gabriel Martins Rodrigues ◽  
Leonardo Pisani ◽  
...  
Keyword(s):  
Ct Perfusion ◽  
Infarct Volume ◽  
Care Center ◽  
Tertiary Care ◽  
Multivariable Analysis ◽  
Functional Independence ◽  
Primary Outcome Measure ◽  
Modified Rankin Scale ◽  
Anterior Circulation ◽  
Vessel Occlusion

BackgroundPatients with large vessel occlusion stroke (LVOS) and a low Alberta Stroke Program Early CT Score (ASPECTS) are often not offered endovascular therapy (ET) as they are thought to have a poor prognosis.ObjectiveTo compare the outcomes of patients with low and high ASPECTS undergoing ET based on baseline infarct volumes.MethodsReview of a prospectively collected endovascular database at a tertiary care center between September 2010 and March 2020. All patients with anterior circulation LVOS and interpretable baseline CT perfusion (CTP) were included. Subjects were divided into groups with low ASPECTS (0–5) and high ASPECTS (6-10) and subsequently into limited and large CTP-core volumes (cerebral blood flow 30% >70 cc). The primary outcome measure was the difference in rates of 90-day good outcome as defined by a modified Rankin Scale (mRS) score of 0 to 2 across groups.Results1248 patients fit the inclusion criteria. 125 patients had low ASPECTS, of whom 16 (12.8%) had a large core (LC), whereas 1123 patients presented with high ASPECTS, including 29 (2.6%) patients with a LC. In the category with a low ASPECTS, there was a trend towards lower rates of functional independence (90-day modified Rankin Scale (mRS) score 0-2) in the LC group (18.8% vs 38.9%, p=0.12), which became significant after adjusting for potential confounders in multivariable analysis (aOR=0.12, 95% CI 0.016 to 0.912, p=0.04). Likewise, LC was associated with significantly lower rates of functional independence (31% vs 51.9%, p=0.03; aOR=0.293, 95% CI 0.095 to 0.909, p=0.04) among patients with high ASPECTS.ConclusionsOutcomes may vary significantly in the same ASPECTS category depending on infarct volume. Patients with ASPECTS ≤5 but baseline infarct volumes ≤70 cc may achieve independence in nearly 40% of the cases and thus should not be excluded from treatment.

Abstract W MP23: Effect of Blood Pressure and Collateral Flow on Infarct Growth Rate

Stroke ◽  
2015 ◽  
Vol 46 (suppl_1) ◽  
Author(s):  
Jamary Oliveira-Filho ◽  
Octavio Pontes-Neto ◽  
Farhad Mehrkhani ◽  
Thabele M Leslie-Mazwi ◽  
Zeshan A Chaudhry ◽  
...  
Keyword(s):  
Blood Pressure ◽  
Growth Rate ◽  
Confidence Interval ◽  
Cerebral Artery ◽  
Infarct Volume ◽  
Brain Mri ◽  
Multivariable Analysis ◽  
Collateral Flow ◽  
Vessel Occlusion ◽  
Point Increase

Objectives: To determine the effect of collateral flow and modifiable risk factors on infarct growth rate. Methods: Consecutive acute ischemic stroke patients admitted with witnessed-onset involving middle cerebral artery (MCA) stem (M1) occlusions underwent brain MRI before intra-arterial therapy. Admission CT angiography was graded for regional leptomeningeal collateral score (rLMC) and infarct volume was measured on diffusion-weighted MRI, both blinded to clinical data. Infarct growth rate was estimated as the ratio between admission infarct volume and time from symptom onset to MRI. Multivariable analysis was performed adjusting for age, sex, vessel occlusion location, smoking and arterial fibrillation. Results: We studied 98 patients over a 10-year period, age 66 +/- 17, median NIH Stroke Scale of 16. Most (36%) patients had isolated M1 occlusions, followed by M1/M2 segment occlusions (34%), M1/distal internal carotid (17%) and M1/distal carotid + anterior cerebral artery occlusions (12%). In the multivariable model, only admission systolic blood pressure (SBP) was significantly associated with infarct growth rate (6.3% lower infarct growth rate for every 10mmHg increase in SBP, 95% confidence interval = 0.3-12.1%, p=0.038). Collateral flow was associated with infarct growth rate among normotensive individuals (13% decrease in infarct growth rate for every 1 point increase in rLMC, 95% confidence interval = 3-23%, p=0.012), but not hypertensive individuals (p=0.019 for interaction). Conclusions: Infarct growth behavior is different between hypertensive and normotensive individuals. While acute high blood pressure is associated with decreased infarct growth rate in both groups, better collateral flow only limits infarct growth in normotensive individuals.

Abstract TP154: Infarct Volume and Prolonged Intubation are Critical Determinants of Inpatient Rehabilitation Cost in Anterior Circulation Large Vessel Occlusion Stroke Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Christopher Streib ◽  
Srikant Rangaraju ◽  
Ashutosh Jadhav ◽  
Tudor Jovin
Keyword(s):  
Infarct Volume ◽  
Univariate Analysis ◽  
Multivariable Analysis ◽  
Inpatient Rehabilitation ◽  
Large Vessel ◽  
P Value ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion

Introduction: Anterior circulation large vessel occlusion (ACLVO) stroke is one of the most devastating stroke subtypes. Significant recent advances, including endovascular thrombectomy, have markedly improved ACLVO stroke outcomes. The economic burden of ACLVO stroke treatment is now an important consideration. Our study investigates the critical determinants of acute inpatient rehabilitation (AIR) cost in ACLVO stroke. Methods: We utilized comprehensive patient-level cost-tracking software to calculate AIR costs for ACLVO stroke patients at our institution between July 2012-October 2014. Cost was calculated from the hospital perspective. Patient demographics, clinical course, neurologic exam, and imaging findings were analyzed. Variables with p-value <0.20 in univariate analysis were included in multivariable analysis to determine significant predictors of AIR cost (p<0.05). Results: 65 patients were included in our analysis (median age 61 [IQR 54-73], median AIR admit NIHSS 12 [6-16]). Univariate analysis results are shown (Figure). In our multivariable analysis the only statistically significant predictors of AIR cost were the patient’s final infarct volume (p<0.001) and intubation >48 hours during the hospitalization (p=0.044). AIR costs increased by $66.46 for every 1 cubic centimeter increase in infarct volume. Conclusion: Infarct volume and intubation >48 hours were significant predictors of AIR cost in ACLVO stroke patients at our institution. ACLVO stroke interventions that limit infarct volume may decrease AIR costs, in addition to avoidance of intubation and aggressive pursuit of extubation when feasible.

Abstract P321: The Cerebral Collateral Cascade: Rethinking the Assessment of Vascular Pathways in Acute Ischemic Stroke Patients

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Tobias D Faizy ◽  
Michael Mlynash ◽  
Reza Kabiri ◽  
Soren Christensen ◽  
Gabriella Kuraitis ◽  
...  
Keyword(s):  
Blood Flow ◽  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Ct Perfusion ◽  
Infarct Volume ◽  
Strong Predictor ◽  
Secondary Outcome ◽  
Collateral Blood Flow ◽  
Vessel Occlusion ◽  
Cortical Vein

Background and Purpose: Robust collateral blood flow in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO) has been correlated with favorable outcomes. Collaterals are commonly assessed by the number of arteries present on non-invasive CT angiography (CTA) overlying ischemic brain, but blood transit from these arteries through the brain tissue and the venous drainage is not assessed by this technique. We hypothesized that a comprehensive imaging analysis of the cerebral collateral cascade (CCC) would predict clinical and radiological outcomes in patients with AIS-LVO patients. Materials and Methods: Multicenter retrospective cohort study of AIS-LVO patients undergoing thrombectomy triage. CCC was determined on pre-treatment imaging by scoring for pial arterial collaterals, tissue-level collaterals (TLC), and venous outflow. Pial arterial collaterals were determined by CTA (Tan scale), TLC were assessed on CT perfusion data using the Hypoperfusion Intensity Ratio, and venous egress was assessed on CTA using the cortical vein opacification score system. 3 groups were defined: CCC+ (good pial collaterals, TLC, and venous perfusion), CCC- (poor pial collaterals, TLC, and venous perfusion) and CCCmixed (reminder of patients). Primary outcome was a good functional outcome (modified Rankin Scale [mRS] 0-2 at 90 days). Secondary outcome was final infarct volume. Results: 647 patients met inclusion criteria: 176 CCC+, 345 CCCmixed and 126 CCC-. Multivariate ordinal logistic regression showed that CCC+ predicted good functional outcomes (mRS 0-2: OR=20.8 [95% CI 9.3-46.8]; p<0.001) compared to CCC- and CCCmixed. CCCmixed (β: 27.1, SE: 7.7; p<0.001) and CCC- (β: 86.6, SE: 9.9; p<0.001) profiles were associated with higher final infarct volumes after treatment compared to CCC+. Conclusion: Comprehensive assessment of the collateral blood flow cascade in AIS-LVO patients is a strong predictor of clinical and radiological outcomes in AIS-LVO patients.

Sign in / Sign up

Export Citation Format

Share Document