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

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.

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

Stroke ◽

10.1161/strokeaha.118.024035 ◽

2019 ◽

Vol 50 (8) ◽

pp. 2238-2240 ◽

Cited By ~ 9

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.

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

Stroke ◽

10.1161/str.51.suppl_1.wp163 ◽

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.

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Early Brain Imaging Shows Increased Severity of Acute Ischemic Strokes With Large Vessel Occlusion in COVID-19 Patients

Stroke ◽

10.1161/strokeaha.120.031011 ◽

2020 ◽

Vol 51 (11) ◽

pp. 3366-3370 ◽

Cited By ~ 3

Author(s):

Simon Escalard ◽

Vanessa Chalumeau ◽

Clément Escalard ◽

Hocine Redjem ◽

François Delvoye ◽

...

Keyword(s):

Brain Imaging ◽

Large Vessel ◽

Neurological Injury ◽

Control Group ◽

Large Vessel Occlusion ◽

Infarct Core ◽

Anterior Circulation ◽

Vessel Occlusion ◽

History Of ◽

Massive Number

Background and Purpose: Reports are emerging regarding the association of acute ischemic strokes with large vessel occlusion and coronavirus disease 2019 (COVID-19). While a higher severity of these patients could be expected from the addition of both respiratory and neurological injury, COVID-19 patients with strokes can present with mild or none respiratory symptoms. We aimed to compare anterior circulation large vessel occlusion strokes severity between patients with and without COVID-19. Methods: We performed a comparative cohort study between patients with COVID-19 who had anterior circulation large vessel occlusion and early brain imaging within 3 hours from onset, in our institution during the 6 first weeks of the COVID-19 outbreak and a control group admitted during the same calendar period in 2019. Results: Twelve COVID-19 patients with anterior circulation large vessel occlusion and early brain imaging were included during the study period and compared with 34 control patients with anterior circulation large vessel occlusion and early brain imaging in 2019. Patients in the COVID-19 group were younger ( P =0.032) and had a history of diabetes mellitus more frequently ( P =0.039). Patients did not significantly differ on initial National Institutes of Health Stroke Scale nor time from onset to imaging ( P =0.18 and P =0.6, respectively). Patients with COVID-19 had more severe strokes than patients without COVID-19, with a significantly lower clot burden score (median: 6.5 versus 8, P =0.016), higher rate of multivessel occlusion (50% versus 8.8%, P =0.005), lower DWI-ASPECTS (Diffusion-Weighted Imaging–Alberta Stroke Program Early CT Scores; median: 5 versus 8, P =0.006), and higher infarct core volume (median: 58 versus 6 mL, P =0.004). Successful recanalization rate was similar in both groups ( P =0.767). In-hospital mortality was higher in the COVID-19 patients’ group (41.7% versus 11.8%, P =0.025). Conclusions: Early brain imaging showed higher severity large vessel occlusion strokes in patients with COVID-19. Given the massive number of infected patients, concerns should be raised about the coming neurovascular impact of the pandemic worldwide.

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

Stroke ◽

10.1161/str.51.suppl_1.tp78 ◽

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

Scientific Reports ◽

10.1038/s41598-021-84269-8 ◽

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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White Matter Acute Infarct Volume After Thrombectomy for Anterior Circulation Large Vessel Occlusion Stroke is Associated with Long Term Outcomes

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2020.105567 ◽

2021 ◽

Vol 30 (3) ◽

pp. 105567

Author(s):

Robert W. Regenhardt ◽

Mark R. Etherton ◽

Alvin S. Das ◽

Markus D. Schirmer ◽

Joshua A. Hirsch ◽

...

Keyword(s):

White Matter ◽

Infarct Volume ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Long Term Outcomes ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Acute Infarct

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Feasibility and safety of the strategy of first stenting without retrieval using Solitaire FR as a treatment for emergent large-vessel occlusion due to underlying intracranial atherosclerosis

Journal of Neurosurgery ◽

10.3171/2020.8.jns202504 ◽

2021 ◽

pp. 1-9

Author(s):

Jong-Hoon Kim ◽

Young-Jin Jung ◽

Chul-Hoon Chang

Keyword(s):

Functional Outcomes ◽

Medical Center ◽

Large Vessel ◽

Intracranial Atherosclerosis ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Stent Retrieval ◽

First Pass ◽

Solitaire Fr

OBJECTIVEThe optimal treatment for underlying intracranial atherosclerosis (ICAS) in patients with emergent large-vessel occlusion (ELVO) remains unclear. Reocclusion during endovascular treatment (EVT) occurs frequently (57.1%–77.3%) after initial recanalization with stent retriever (SR) thrombectomy in ICAS-related ELVO. This study aimed to compare treatment outcomes of the strategy of first stenting without retrieval (FRESH) using the Solitaire FR versus SR thrombectomy in patients with ICAS-related ELVO.METHODSThe authors retrospectively reviewed consecutive patients with acute ischemic stroke and intracranial ELVO of the anterior circulation who underwent EVT between January 2017 and December 2019 at Yeungnam University Medical Center. Large-vessel occlusion (LVO) of the anterior circulation was classified by etiology as follows: 1) no significant stenosis after recanalization (embolic group) and 2) remnant stenosis > 70% or lesser degree of stenosis with a tendency toward reocclusion and/or flow impairment during EVT (ICAS group). The ICAS group was divided into the SR thrombectomy group (SR thrombectomy) and the FRESH group.RESULTSA total of 105 patients (62 men and 43 women; median age 71 years, IQR 62.5–79 years) were included. The embolic, SR thrombectomy, and FRESH groups comprised 66 (62.9%), 26 (24.7%), and 13 (12.4%) patients, respectively. There were no significant differences between the SR thrombectomy and FRESH groups in symptom onset–to-door time, but puncture-to-recanalization time was significantly shorter in the latter group (39 vs 54 minutes, p = 0.032). There were fewer stent retrieval passes but more first-pass recanalizations in the FRESH group (p < 0.001). Favorable functional outcomes were significantly more frequent in the FRESH group (84.6% vs 42.3%, p = 0.017).CONCLUSIONSThis study’s findings suggest that FRESH, rather than rescue stenting, could be a treatment option for ICAS-related ELVO.

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Abstract 31: Penumbra Consumption Rates Based on T Max Delay and Reperfusion Status: A Post-Hoc Analysis of the Defuse-3 Trial

Stroke ◽

10.1161/str.52.suppl_1.31 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Shadi Yaghi ◽

Eytan Raz ◽

Seena Dehkharghani ◽

Howard Riina ◽

Ryan McTaggart ◽

...

Keyword(s):

Infarct Volume ◽

Secondary Analysis ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Consumption Rates ◽

Definition Of ◽

Post Hoc ◽

New Generation

Introduction: In patients with acute large vessel occlusion, the definition of penumbral tissue based on T max delay perfusion imaging is not well established in relation to late-window endovascular thrombectomy (EVT). In this study, we sought to evaluate penumbra consumption rates for T max delays in patients treated between 6 and 16 hours from last known normal. Methods: This is a secondary analysis of the DEFUSE-3 trial, which included patients with an acute ischemic stroke due to anterior circulation occlusion within 6-16 hours of last known normal. The primary outcome is percentage penumbra consumption defined as (24 hour infarct volume-core infarct volume)/(Tmax volume-baseline core volume). We stratified the cohort into 4 categories (untreated, TICI 0-2a, TICI 2b, and TICI3) and calculated penumbral consumption rates. Results: We included 143 patients, of which 66 were untreated, 16 had TICI 0-2a, 46 had TICI 2b, and 15 had TICI 3. In untreated patients, a median (IQR) of 48% (21% - 85%) of penumbral tissue was consumed based on Tmax6 as opposed to 160.6% (51% - 455.2%) of penumbral tissue based on Tmax10. On the contrary, in patients achieving TICI 3 reperfusion, a median (IQR) of 5.3% (1.1% - 14.6%) of penumbral tissue was consumed based on Tmax6 and 25.7% (3.2% - 72.1%) of penumbral tissue based on Tmax10. Conclusion: Contrary to prior studies, we show that at least 75% of penumbral tissue with Tmax > 10 sec delay can be salvaged with successful reperfusion and new generation devices. In untreated patients, since infarct expansion can occur beyond 24 hours, future studies with delayed brain imaging are needed to determine the optimal T max delay threshold that defines penumbral tissue in patients with proximal anterior circulation large vessel occlusion.

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Abstract 202: Endovascular Therapy for Acute Ischemic Stroke With Distal Large Vessel Occlusion in the Anterior Circulation

Stroke ◽

10.1161/str.47.suppl_1.202 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Amrou Sarraj ◽

Navdeep Sangha ◽

Muhammad Shazam Hussain ◽

Dolora Wisco ◽

Nirav Vora ◽

...

Keyword(s):

Endovascular Therapy ◽

Primary Outcome ◽

Large Vessel ◽

Secondary Outcome ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Good Outcome ◽

Baseline Characteristics ◽

Iv Tpa

Introduction: Five RCTs demonstrated the superiority of endovascular therapy (EVT) over best medical management (MM) for acute ischemic strokes (AIS) with large vessel occlusion (LVO) in the anterior circulation. Patients with M2 occlusions, however, were underrepresented (95 randomized; 51 EVT treated). Evidence from RCTs of the benefit of EVT for M2 occlusions is lacking, as reflected in the recent AHA guidelines. Methods: A retrospective cohort was pooled from 10 academic centers from 1/12 to 4/15 of AIS patients with LVO isolated to M2 presenting within 8 hours from last known normal (LKN). Patients were divided into EVT and MM groups. Primary outcome was 90 day mRS (good outcome 0-2); secondary outcome was sICH. Logistic regression compared the 2 groups. Univariate and multivariate analyses evaluated predictors of good outcome in the EVT group. Results: Figure 1 shows participating centers, 522 patients (288 EVT and 234 MM) were identified. Table (1) shows baseline characteristics. MM treated patients were older and had higher IV tPA treatment rates, otherwise the 2 groups were balanced. 62.7 % EVT patients had mRS 0-2 at 90 days compared to 35.4 % MM (figure 2). EVT patients had 3 times the odds of good outcome as compared to MM patients (OR: 3.1, 95% CI:2.1-4.4, P <0.001) even after adjustment for age, NIHSS, ASPECTS, IV tPA and LKN to door time (OR: 3.2, 95%CI: 2-5.2, P<0.001). sICH rate was 5.6 %, which was not statistically different than the MM group (table 1, P=0.1). Age, NIHSS, good ASPECTS, LKN to reperfusion time and successful reperfusion mTICI ≥ 2b were independent predictors of good outcome in EVT patients. There was a linear relationship between good outcome and time LKN to reperfusion (Figure 3). Conclusion: Despite inherent limitations of its retrospective design, our study suggests that EVT may be effective and safe for distal LVO (M2) relative to best MM. A trial randomizing M2 occlusions to EVT vs. MM is warranted to confirm these findings.

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