scholarly journals Ischemic lesion water homeostasis after thrombectomy for large vessel occlusion stroke within the anterior circulation: The impact of age

2020 ◽  
Vol 41 (1) ◽  
pp. 45-52 ◽  
Author(s):  
Lukas Meyer ◽  
Michael Schönfeld ◽  
Matthias Bechstein ◽  
Uta Hanning ◽  
Bastian Cheng ◽  
...  
Keyword(s):  
Regression Analysis ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Edema Formation ◽  
Ischemic Lesion ◽  
Younger Patients ◽  
Younger Age ◽  
Multivariable Regression ◽  
The Impact

The effect of age on lesion pathophysiology in the context of thrombectomy has been poorly investigated. We aimed to investigate the impact of age on ischemic lesion water homeostasis measured with net water uptake (NWU) within a multicenter cohort of patients receiving thrombectomy for anterior circulation large vessel occlusion (LVO) stroke. Lesion-NWU was quantified in multimodal CT on admission and 24 h for calculating Δ-NWU as their difference. The impact of age and procedural parameters on Δ-NWU was analyzed. Multivariable regression analysis was performed to identify significant predictors for Δ-NWU. Two hundred and four patients with anterior circulation stroke were included in the retrospective analysis. Comparison of younger and elderly patients showed no significant differences in NWU on admission but significantly higher Δ-NWU ( p = 0.005) on follow-up CT in younger patients. In multivariable regression analysis, higher age was independently associated with lowered Δ-NWU (95% confidence interval: −0.59 to −0.16, p < 0.001). Although successful recanalization (TICI ≥ 2b) significantly reduced Δ-NWU progression by 6.4% ( p < 0.001), younger age was still independently associated with higher Δ-NWU ( p < 0.001). Younger age is significantly associated with increased brain edema formation after thrombectomy for LVO stroke. Younger patients might be particularly receptive targets for future adjuvant neuroprotective drugs that influence ischemic edema formation.

Abstract TP74: Aspects Scoring Applied to CTA Source Images is Predictive of Final Infarct Volume and Good Functional Outcome

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Joseph F Carrera ◽  
Joseph H Donahue ◽  
Prem P Batchala ◽  
Andrew M Southerland ◽  
Bradford B Worrall
Keyword(s):  
Linear Regression ◽  
Functional Outcome ◽  
Infarct Volume ◽  
Univariate Analysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
The Impact

Introduction: CTP and MRI are increasingly used to assess endovascular thrombectomy (EVT) candidacy in large vessel occlusion stroke. Unfortunately, availability of these advanced neuroimaging techniques is not widespread and this can lead to over-triage to EVT-capable centers. Hypothesis: ASPECTS scoring applied to computed tomography angiography source images (CTA-SI) will be predictive of final infarct volume (FIV) and functional outcome. Methods: We reviewed data from consecutive patients undergoing EVT at our institution for anterior circulation occlusion between 01/14 - 01/19. We recorded demographics, comorbidities, NIHSS, treatment time parameters, and outcomes as defined by mRS (0-2 = good outcome). Cerebrovascular images were assessed by outcome-blinded raters and collateral score, TICI score, FIV, and both CT and CTA-SI ASPECTS scores were noted. Patients were grouped by ASPECTS score into low (0-4), intermediate (5-7), and high (8-10) for some analyses. FIV was predicted using a linear regression with NIHSS, good reperfusion (TICI 2b/3), collateral score, CT to groin puncture, CT and CTA-SI ASPECTS as independent variables. After excluding those with baseline mRS≥2, a binary logistic regression was performed including covariates of age, NIHSS, good reperfusion, and diabetes (factors significant at p<0.05 on univariate analysis) to assess the impact of CTA-SI ASPECTS group on outcome. Results: Analysis included 137 patients for FIV and 102 for outcome analysis (35 excluded for baseline mRS≥ 2). Linear regression found CTA-SI ASPECTS (Beta -10.8, p=0.002), collateral score (Beta -42.9, p=0.001) and good reperfusion (Beta 72.605, p=0.000) were independent predictors of FIV. Relative to the low CTA-SI ASPECTS group, the high CTA-SI ASPECTS group was more likely to have good outcome (OR 3.75 [95% CI 1.05-13.3]; p=0.41). CT ASPECTS was not predictive of FIV or good outcome. Outcomes: In those undergoing EVT for anterior circulation occlusion, CTA-SI ASPECTS is predictive of both FIV and functional outcome, while CT ASPECTS predicts neither. CTA-SI ASPECTS holds promise as a lower-cost, more widely available option for triage of patients with large vessel occlusion. Further study is needed comparing CTA-SI ASPECTS to CTP parameters.

Rescue of Neglect and Language Impairment After Stroke Thrombectomy

Stroke ◽  
2021 ◽  
Author(s):  
Shashvat M. Desai ◽  
Konark Malhotra ◽  
Guru Ramaiah ◽  
Daniel A. Tonetti ◽  
Waqas Haq ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Language Impairment ◽  
Functional Independence ◽  
National Institutes Of Health ◽  
Large Vessel ◽  
Lower Mortality ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
The Impact

BACKGROUND AND PURPOSE: Although National Institutes of Health Stroke Scale scores provide an objective measure of clinical deficits, data regarding the impact of neglect or language impairment on outcomes after mechanical thrombectomy (MT) is lacking. We assessed the frequency of neglect and language impairment, rate of their rescue by MT, and impact of rescue on clinical outcomes. Methods: This is a retrospective analysis of a prospectively collected database from a comprehensive stroke center. We assessed right (RHS) and left hemispheric strokes (LHS) patients with anterior circulation large vessel occlusion undergoing MT to assess the impact of neglect and language impairment on clinical outcomes, respectively. Safety and efficacy outcomes were compared between patients with and without rescue of neglect or language impairment. Results: Among 324 RHS and 210 LHS patients, 71% of patients presented with neglect whereas 93% of patients had language impairment, respectively. Mean age was 71±15, 56% were females, and median National Institutes of Health Stroke Scale score was 16 (12–20). At 24 hours, MT resulted in rescue of neglect in 31% of RHS and rescue of language impairment in 23% of LHS patients, respectively. RHS patients with rescue of neglect (56% versus 34%, P <0.001) and LHS patients with rescue of language impairment (64 % versus 25%, P <0.01) were observed to have a higher rate of functional independence compared to patients without rescue. After adjusting for confounders including 24-hour National Institutes of Health Stroke Scale, rescue of neglect among RHS patients was associated with functional independence ( P =0.01) and lower mortality ( P =0.01). Similarly, rescue of language impairment among LHS patients was associated with functional independence ( P =0.02) and lower mortality ( P =0.001). ConclusionS: Majority of LHS-anterior circulation large vessel occlusion and of RHS-anterior circulation large vessel occlusion patients present with the impairment of language and neglect, respectively. In comparison to 24-hour National Institutes of Health Stroke Scale, rescue of these deficits by MT is an independent and a better predictor of functional independence and lower mortality.

Abstract 60: Impact of Monthly Testing and Tutorials on Accuracy and Confidence of Telestroke Nurse Recognition of Anterior Circulation Large Vessel Occlusion CT Perfusion Patterns

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Emily K Snider ◽  
Brenda Chang ◽  
Anna Maria Helms ◽  
Laura Williams ◽  
Sam Singh ◽  
...  
Keyword(s):  
Good Accuracy ◽  
Internal Carotid ◽  
Ct Perfusion ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Confidence Levels ◽  
Lower Confidence ◽  
The Impact

Introduction: A distinguishing feature of our Stroke Network is Telestroke (TS) nurses (RNs) who remotely facilitate TS evaluations. To facilitate expeditious transfer the TS RNs, need to immediately identify CT perfusion (CTP) studies demonstrating patterns consistent with internal carotid artery (ICA), middle cerebral artery (M1), and first branch of the M1 (M2) large vessel occlusion (LVO) acute ischemic strokes (AIS). Methods: We developed a 6-month series of tutorials and tests (12 CTP scans/month) for 16 TS RNs to recognize CTP patterns consistent with ICA, M1 or M2 LVO AIS. We simultaneously conducted a prospective cohort study of these nurses on the impact of these tutorials and tests. Results: TS nurses demonstrated good accuracy in detecting ICA, M1 or M2 LVO presence during the first three months of teaching (83-94% accurate).This improved to excellent during the last three months (99-100%), during which the likelihood of correctly identifying the presence of any one of these LVOs was greater than in the first three months (OR 1.99, 95% CI: 1.83-2.17, p<0.001). The probability of correctly identifying ICA or M1 occlusions was much higher than correctly identifying all other LVOs (OR 68, 95% CI: 45-102, p<0.001). The likelihood of being at a higher confidence level compared to lower confidence levels in identifying any LVOs as being ICA or M1 was higher than in identifying other LVOs (OR 2.14, 95% CI: 1.6-2.8, p<0.001), but over time confidence for determining LVO presence did not differ significantly after controlling for subject variation. Conclusion: A series of structured tutorials significantly increased the odds of TS nurses correctly identifying anterior circulation LVOs, with the benefit of these tutorials and test reviews peaking and plateauing at four months. Participating in TS nurse tutorials was associated with high odds and confidence for correctly identifying LVOs as being ICA or M1.

scholarly journals Impact of onset-to-groin puncture time within three hours on functional outcomes in mechanical thrombectomy for acute large-vessel occlusion

2017 ◽  
Vol 24 (2) ◽  
pp. 162-167 ◽  
Author(s):  
Takahiro Ota ◽  
Yasuhiro Nishiyama ◽  
Satoshi Koizumi ◽  
Tomonari Saito ◽  
Masayuki Ueda ◽  
...  
Keyword(s):  
Scale Score ◽  
Functional Outcomes ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Multivariable Logistic Regression Analysis ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Stroke Treatment ◽  
The Impact

Introduction Endovascular treatment for acute ischemic stroke with acute large-vessel occlusion (ALVO) has established benefits, and rapid treatment is vital for mechanical thrombectomy in ALVO. Time from onset of stroke to groin puncture (OTP) is a practical and useful clinical marker, and OTP should be shortened to obtain the maximum benefit of thrombectomy. Objective The aim of the present study was to assess the impact of early treatment of anterior circulation stroke within three hours after symptom onset and to evaluate the role of OTP in determining outcomes after endovascular therapy. Methods Consecutive patients with acute stroke due to major artery (internal carotid or middle cerebral arteries) occlusion who underwent endovascular recanalization between March 2014 and January 2017 were retrospectively evaluated. Patients were stratified by OTP into three categories: 0–≤3 h, >3–≤6 h, and >6 h. The primary outcome measure was a 90-day modified Rankin scale score of 0–2 (good outcome). Results Data were analyzed from 100 patients (mean age, 76.6 years; mean National Institutes of Health Stroke Scale score, 17). Groin puncture occurred within 0–≤3 h in 51 patients, >3–≤6 h in 28, and >6 h in 21. Median OTP in each group was 126 min (range, 57–168 min), 238 min (range, 186–360 min) and 728 min (range, 365–1492 min), respectively. On multivariable logistic regression analysis, category of OTP represented an independent predictor of patient outcome (adjusted odds ratio, 0.48; 95% confidence interval, 0.25–0.93; p = 0.029). Conclusions OTP is a prehospital and in-hospital workflow-based indicator. In this single-center study, OTP was found to independently affect functional outcomes after endovascular stroke treatment.

Is Reperfusion Useful in Ischaemic Stroke Patients Presenting with a Low National Institutes of Health Stroke Scale and a Proximal Large Vessel Occlusion of the Anterior Circulation?

2017 ◽  
Vol 43 (5-6) ◽  
pp. 305-312 ◽  
Author(s):  
Cyril Dargazanli ◽  
Arturo Consoli ◽  
Benjamin Gory ◽  
Raphaël Blanc ◽  
Julien Labreuche ◽  
...  
Keyword(s):  
Ischaemic Stroke ◽  
Favourable Outcome ◽  
National Institutes Of Health ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Excellent Outcome ◽  
Mild Stroke ◽  
The Impact

Background: In population-based studies, patients presenting with minor or mild stroke symptoms represent about two-thirds of stroke patients, and almost one-third of these patients are unable to ambulate independently at the time of discharge. Although mechanical thrombectomy (MT) has become the standard of care for acute ischaemic stroke with proximal large vessel occlusion (LVO) in the anterior circulation, the management of patients harbouring proximal occlusion and minor-to-mild stroke symptoms has not yet been determined by recent trials. The purpose of this study was to evaluate the impact of reperfusion on clinical outcome in low National Institutes of Health Stroke Scale (NIHSS) patients treated with MT. Methods: We analysed 138 consecutive patients with acute LVO of the anterior circulation (middle cerebral artery M1 or M2 segment, internal carotid artery or tandem occlusion) with NIHSS <8, having undergone MT in 3 different centres. Reperfusion was graded using the modified thrombolysis in cerebral infarction (TICI) score and 3 grades were defined, ranging from failed or poor reperfusion (TICI 0, 1, 2A) to complete reperfusion (TICI 3). The primary clinical endpoint was an excellent outcome defined as a modified Rankin score (mRs) 0-1 at 3-months. The impact of reperfusion grade was assessed in univariate and multivariate analyses. The secondary endpoints included favourable functional outcome (90-day mRS 0-2), death and safety concerns. Results: Successful reperfusion was achieved in 81.2% of patients (TICI 2B, n = 47; TICI 3, n = 65). Excellent outcome (mRs 0-1) was achieved in 69 patients (65.0%) and favourable outcome (mRs ≤2) in 108 (78.3%). Death occurred in 7 (5.1%). Excellent outcome increased with reperfusion grades, with a rate of 34.6% in patients with failed/poor reperfusion, 61.7% in patients with TICI 2B reperfusion, and 78.5% in patients with TICI 3 reperfusion (p < 0.001). In multivariate analysis adjusted for patient characteristics associated with excellent outcome, the reperfusion grade remained significantly associated with an increase in excellent outcome; the OR (95% CI) was 3.09 (1.06-9.03) for TICI 2B and 6.66 (2.27-19.48) for TICI 3, using the failed/poor reperfusion grade as reference. Similar results were found regarding favourable outcome (90-day mRs 0-2) or overall mRS distribution (shift analysis). Conclusion: Successful reperfusion is strongly associated with better functional outcome among patients with proximal LVO in the anterior circulation and minor-to-mild stroke symptoms. Randomized controlled studies are mandatory to assess the benefit of MT compared with optimal medical management in this subset of patients.

scholarly journals Effect of thrombectomy on oedema progression and clinical outcome in patients with a poor collateral profile

2020 ◽  
pp. svn-2020-000570
Author(s):  
Gabriel Broocks ◽  
Andre Kemmling ◽  
Tobias Faizy ◽  
Rosalie McDonough ◽  
Noel Van Horn ◽  
...  
Keyword(s):  
Clinical Outcome ◽  
Ischaemic Stroke ◽  
Linear Regression Analysis ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Oedema Formation ◽  
Vessel Occlusion ◽  
Multivariable Linear Regression Analysis ◽  
The Impact

Background and purposeThe impact of the cerebral collateral circulation on lesion progression and clinical outcome in ischaemic stroke is well established. Moreover, collateral status modifies the effect of endovascular treatment and was therefore used to select patients for therapy in prior trials. The purpose of this study was to quantify the effect of vessel recanalisation on lesion pathophysiology and clinical outcome in patients with a poor collateral profile.Materials and methods129 patients who had an ischaemic stroke with large vessel occlusion in the anterior circulation and a collateral score (CS) of 0–2 were included. Collateral profile was defined using an established 5-point scoring system in CT angiography. Lesion progression was determined using quantitative lesion water uptake measurements on admission and follow-up CT (FCT), and clinical outcome was assessed using modified Rankin Scale (mRS) scores after 90 days.ResultsOedema formation in FCT was significantly lower in patients with vessel recanalisation compared with patients with persistent vessel occlusion (mean 19.5%, 95% CI: 17% to 22% vs mean 27%, 95% CI: 25% to 29%; p<0.0001). In a multivariable linear regression analysis, vessel recanalisation was significantly associated with oedema formation in FCT (ß=−7.31, SD=0.015, p<0.0001), adjusted for CS, age and Alberta Stroke Program Early CT Score (ASPECTS). Functional outcome was significantly better in patients following successful recanalisation (mRS at day 90: 4.5, IQR: 2–6 vs 5, IQR: 5–6, p<0.001).ConclusionAlthough poor collaterals are known to be associated with poor outcome, endovascular recanalisation was still associated with significant oedema reduction and comparably better outcome in this patient group. Patients with poor collaterals should not generally be excluded from thrombectomy.

Abstract WP80: Thrombus Imaging Characteristics and Association With Functional Outcomes in Patients Undergoing Endovascular Treatment

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
David K Tang ◽  
Zhi-Xuan Ng ◽  
Joshua Yeo ◽  
Benjamin Y Tan ◽  
Christopher Y Chua ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Functional Outcomes ◽  
Patient Characteristics ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Thrombus Imaging ◽  
Imaging Characteristics ◽  
Younger Age ◽  
Clot Burden

Background: Intracranial thrombus characteristics on computed tomography angiography (CTA) in patients undergoing endovascular therapy (ET) for anterior circulation large vessel occlusion (LVO) acute ischemic stroke (AIS) has been shown to be useful in prognosticating functional outcomes. We establish if thrombus characteristics on non-contrast computed tomography (CT) scans and CTA were associated with clinical outcomes. Methods: We included 257 patients with anterior circulation LVO AIS from our Hyper-Acute Stroke Thrombolysis and Endovascular (HASTEN) registry treated at our tertiary academic institution from 2014-2018. We evaluated associations of patient’s characteristics and thrombus imaging characteristics with patients’ functional outcomes, scored with the modified Rankin Scale (MRS) at 3 months. Imaging characteristics were assessed on CT and CTA. Patient characteristics included age, presence of co-morbidities, initial NIHSS and ASPECTS. Thrombus characteristics included presence of hyperdense middle cerebral artery (MCA) sign, CT dense MCA length, CTA location and length of thrombus, CTA clot burden score (CBS) and recanalization status (mTICI). A good functional outcome was defined as patients who achieved an MRS of 0-2 at 3 months. Results: Patient characteristics associated with good functional outcomes were younger age, absence of diabetes mellitus, lower NIHSS, higher ASPECTS and successful recanalization measured by a mTICI 2b/3 (Table 1). Thrombus characteristics associated with good functional outcomes were a shorter CT dense MCA length and a higher CTA CBS (Table 1). Of note, presence of a hyperdense MCA sign on CT and CTA thrombus length were not significantly associated with good functional outcomes. Conclusions: In patients with anterior circulation LVO AIS, a shorter CT dense MCA length and a higher CTA CBS were associated with good functional outcomes, and may aid in improving patient selection.

Abstract TP2: Impact of Neglect on Outcomes After Right Hemisphere Stroke Thrombectomy

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Shashvat M Desai ◽  
Guru Ramaiah ◽  
Waqas Haq ◽  
Kunakorn Atchaneeyasakul ◽  
Matthew Starr ◽  
...  
Keyword(s):  
Right Hemisphere ◽  
Multivariate Analyses ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Nihss Score ◽  
Younger Age ◽  
Severe Motor ◽  
Comprehensive Stroke Center ◽  
Stroke Center ◽  
The Impact

Introduction: Right Hemisphere Strokes (RHS) are characterized by severe motor and sensory deficits and signs of neglect including extinction and inattention. National Institutes of Health Stroke Scale (NIHSS) score provides an objective measurement of presence or absence of neglect. Data regarding the impact of neglect on outcomes after RHS thrombectomy are lacking. We hypothesize that the presence of neglect in RHS is associated with worse outcomes after thrombectomy in RHS. Methods: Retrospective analysis of prospectively collected database of right sided anterior circulation large vessel occlusion [internal carotid and/or middle cerebral artery M1] strokes at a comprehensive stroke center. Patients with successful recanalization (TICI≥ 2B) and complete follow-up data were included in the study. Two group of RHS were identified- with and without neglect by itemized NIHSS. Baseline characteristics and outcomes were compared. Results: A total of 172 patients were included in the study. Median NIHSS score was 15 (11-18) and median ASPECTS was 9 (8-10). Signs of neglect were observed in 63% (108) of patients. In multivariate analyses, younger age [0.9 (0.8-0.95) p=<0.01] and higher ASPECTS [1.8 (1.1-3.1) p=0.015] were independent predictors of mRS 0-2 at 90 days. Absence of neglect [0.39 (0.13-1.1) p=0.07] may predict good outcome. Independent predictors of mortality on multivariate analyses included older age [1.1 (1.03-1.15) p =0.001], presence of atrial fibrillation [0.3 (0.1-1) p=0.05] and diabetes mellitus [0.16 (0.05-0.53) p=0.003]. Presence of neglect [2.5 (0.9-6.6) p=0.06] and lower ASPECTS [0.7 (0.4-1) p=0.06] may predict mortality. Conclusion: Signs of neglect were observed in approximately 63% of right hemisphere LVO strokes. Presence of neglect may predict poor functional outcome and mortality at 90 days after thrombectomy for right hemisphere strokes. Further studies are required to evaluate the impact of thrombectomy on recovery of neglect.

scholarly journals Factors associated with prominent vessel sign on susceptibility-weighted imaging in acute ischemic stroke

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Hai-fei Jiang ◽  
Yi-qun Zhang ◽  
Jiang-xia Pang ◽  
Pei-ning Shao ◽  
Han-cheng Qiu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Large Vessel ◽  
Susceptibility Weighted Imaging ◽  
Regression Analyses ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Factors Associated ◽  
Univariate Analyses

AbstractThe prominent vessel sign (PVS) on susceptibility-weighted imaging (SWI) is not displayed in all cases of acute ischemia. We aimed to investigate the factors associated with the presence of PVS in stroke patients. Consecutive ischemic stroke patients admitted within 24 h from symptom onset underwent emergency multimodal MRI at admission. Associated factors for the presence of PVS were analyzed using univariate analyses and multivariable logistic regression analyses. A total of 218 patients were enrolled. The occurrence rate of PVS was 55.5%. Univariate analyses showed significant differences between PVS-positive group and PVS-negative group in age, history of coronary heart disease, baseline NIHSS scores, total cholesterol, hemoglobin, anterior circulation infarct, large vessel occlusion, and cardioembolism. Multivariable logistic regression analyses revealed that the independent factors associated with PVS were anterior circulation infarct (odds ratio [OR] 13.7; 95% confidence interval [CI] 3.5–53.3), large vessel occlusion (OR 123.3; 95% CI 33.7–451.5), and cardioembolism (OR 5.6; 95% CI 2.1–15.3). Anterior circulation infarct, large vessel occlusion, and cardioembolism are independently associated with the presence of PVS on SWI.

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