scholarly journals Predictors of mortality for patients with COVID-19 and large vessel occlusion

2020 ◽  
Vol 26 (5) ◽  
pp. 623-628 ◽  
Author(s):  
David J Altschul ◽  
Charles Esenwa ◽  
Neil Haranhalli ◽  
Santiago R Unda ◽  
Rafael de La Garza Ramos ◽  
...  
Keyword(s):  
Cigarette Smoking ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Old Patients ◽  
Risk Of Mortality ◽  
Increased Risk ◽  
History Of ◽  
Radiographic Data ◽  
D Dimer

Background This study evaluates the mortality risk of patients with emergent large vessel occlusion (ELVO) and COVID-19 during the pandemic. Methods We performed a retrospective cohort study of two cohorts of consecutive patients with ELVO admitted to a quaternary hospital from March 1 to April 17, 2020. We abstracted data from electronic health records on baseline, biomarker profiles, key time points, quality measures and radiographic data. Results Of 179 patients admitted with ischemic stroke, 36 had ELVO. Patients with COVID-19 and ELVO had a higher risk of mortality during the pandemic versus patients without COVID-19 (OR 16.63, p = 0.004). An age-based sub-analysis showed in-hospital mortality in 60% of COVID-19 positive patients between 61-70 years-old, 66.7% in between 51-60 years-old, 50% in between 41-50 years-old and 33.3% in between 31-40 years old. Patients that presented with pulmonary symptoms at time of stroke presentation had 71.4% mortality rate. 27.3% of COVID-19 patients presenting with ELVO had a good outcome at discharge (mRS 0-2). Patients with a history of cigarette smoking (p = 0.003), elevated d-dimer (p = 0.007), failure to recanalize (p = 0.007), and elevated ferritin levels (p = 0.006) had an increased risk of mortality. Conclusion Patients with COVID-19 and ELVO had a significantly higher risk for mortality compared to COVID-19 negative patients with ELVO. A small percentage of COVID-19 ELVO patients had good outcomes. Age greater than 60 and pulmonary symptoms at presentation have higher risk for mortality. Other risk factors for mortality were a history of cigarette smoking, elevated, failure to recanalize, elevated d-dimer and ferritin levels.

Abstract P558: Identification of Embolic Stroke in Patients With Large Vessel Occlusion

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Lan Hong ◽  
Longting Lin ◽  
Gang Li ◽  
Jianhong Yang ◽  
Geng Yu ◽  
...  
Keyword(s):  
Perfusion Imaging ◽  
Delay Time ◽  
Validation Cohort ◽  
Embolic Stroke ◽  
Large Vessel ◽  
Smoking History ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Derivation Cohort ◽  
History Of

Objective: To develop a simple and objective score using clinical variables and quantified perfusion measures to identify embolic stroke with large vessel occlusions. Methods: Eligible patients from the Chinese centers participating in the International Stroke Perfusion Imaging Registry were included in this study. Patients were split into a derivation cohort (n=213) and a validation cohort (n=116). A score was developed according to the coefficients of independent predictors of embolic stroke from stepwise logistic regression model in the derivation cohort. The performance of the score was validated by assessing its discrimination and calibration. Additionally, a comparison between the area under curve (AUC) of history of atrial fibrillation (AF) alone and history of AF plus the score was also conducted. Results: The independent predictors of embolic stroke made up the Chinese Embolic Stroke Score (CHESS). There were: age (≥64 years, 1 point), non-smoking history (1 point), non-hypertension history (1 point) , baseline NIH Stroke Scale (≥14, 1 point) and delay time>6s volume/delay time>3s volume on perfusion imaging (≥0.23, 2 points). The AUC of CHESS in the derivation cohort and validation cohort were 0.80 and 0.72 respectively. Calibration tests indicated high agreement between predicted and observed probabilities. The AUC of AF-plus-CHESS compared to history of AF alone was significant (derivation cohort P<0.001; validation cohort P=0.01). Conclusions: In a Chinese population, CHESS reliably and independently identified embolic stroke as the cause of large vessel occlusion.

Abstract P345: Perfusion-Guided Bridging Therapy in Strokes With Unknown Time of Onset and Large Vessel Occlusion

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Jose Bernardo Escribano Paredes ◽  
Julian Klug ◽  
Elisabeth Dirren ◽  
Nicolae Sanda ◽  
Maria Vargas ◽  
...  
Keyword(s):  
Intravenous Thrombolysis ◽  
Stroke Onset ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Bridging Therapy ◽  
Vessel Occlusion ◽  
Intracerebral Bleeding ◽  
Interhospital Transfer ◽  
Symptom Recognition ◽  
Increased Risk

Introduction: Endovascular treatment (EVT) is the therapy of choice, in patients with unknown stroke onset (unwitnessed and wake-up strokes) and large vessel occlusion (LVO) with a favorable perfusion pattern. Whether bridging therapy (intravenous thrombolysis (IVT) and EVT) is superior to EVT alone remains unknown. Material and Methods: We retrospectively included all patients admitted to the Geneva University Hospital from 01.2016 to 06.2020 with i) stroke of unknown onset, due to ii) anterior circulation occlusion, with iii) favorable CT perfusion pattern based on the DEFUSE criteria (ischemic core volume< 70ml; mismatch ratio >= 1.8 and mismatch volume >= 15ml), and iv) treated < 4.5 hours after symptom recognition. As a standard of care, the patients fulfilling these inclusion criteria were treated with EVT and IVT or EVT alone when IVT was contraindicated. Outcome measures were any intracerebral bleeding (symptomatic or asymptomatic), mortality and favorable outcome (mRS 0-1) at three months. Results: 32 patients were included (17 treated with EVT alone and 15 with EVT and IVT). Mean age was 69±18 yo. Median NIHSS was 16 (IQR 12-20) and median time from symptom recognition to treatment was 184 (146-226) minutes. Median hypoperfused tissue volume (Tmax > 6s) was 119 ml (80-151) and infarcted core (CBF ratio <30%) 8 ml (0-27). After propensity score weighting, bridging therapy was not associated with an increased risk of intracerebral bleeding (p=0.72) or mortality (p=0.55). The proportion of favorable outcomes at three months was similar between treatment groups (p=0.78). Conclusion: These results suggest that IVT before EVT is a safe therapeutic option in patients with unknown stroke onset selected on perfusion imaging and treated <4.5 hours after symptom recognition. Early administration of IVT may be particularly relevant before interhospital transfer to a comprehensive stroke center for EVT.

Abstract 194: Preliminary Results from the FIRST Trial: Natural History of Acute Stroke from Large Vessel Occlusion

Stroke ◽  
2013 ◽  
Vol 44 (suppl_1) ◽  
Author(s):  
Vallabh Janardhan ◽  
Ryan M Gianatasio ◽  
Sherman H Chen ◽  
Parita Bhuva ◽  
Mark M Murray ◽  
...  
Keyword(s):  
Placebo Group ◽  
Natural History ◽  
Interim Analysis ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Adverse Event Rate ◽  
Delayed Presentation ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
History Of

Purpose: Current literature has limited information on the natural history of the stroke cohort eligible for mechanical thrombectomy. The placebo group from the PROACT II study is often used as a historical control, despite differences in entry criteria. Reported herein are data in a stroke cohort eligible for mechanical thrombectomy but untreated due to unavailability or inability to initiate endovascular treatment within the 8-hr window due to delayed presentation. The goal is to compare the functional independence rate with the PROACT placebo group. Methods: The FIRST Trial is a prospective, multicenter, natural history study of a stroke cohort eligible for but untreated by mechanical thrombectomy presenting within 8 hrs of symptom onset from a large vessel occlusion and a NIHSS of at least 10. The primary endpoint is functional outcome at 90 days as defined by a mRS 0-2. Results are reported from an interim analysis. Results: Fifty-nine (59) patients were enrolled and met study criteria for this interim analysis. The mean age was 68.2 ± 17 years; median NIHSS was 18 (5-34). Target vessel occlusions were in the ICA (35.7%), MCA (60.7%), and other (3.6%). At admission, the TIMI 0-1 rate was 89% (49/55), and the TICI 0-1 rate was 89% (48/54). Of these, only 10% (3/30) showed spontaneous recanalization (TIMI 2-3 or TICI 2a-3). Eleven of 55 (20%) patients achieved a good 90-day outcome, and 24 of 59 (40.7%) died. The serious adverse event rate was 52.6% (30/57), including respiratory failure (8 cases) and pneumonia (4 cases). A total of 6 (10%) patients suffered intracerebral hemorrhage (ICH). Below is a comparison of the MCA cohort vs. PROACT II placebo patients. Conclusion: Compared with PROACT II placebo patients, the stroke cohort eligible for mechanical thrombectomy who were untreated have a lower rate of recanalization and worse outcome. These results indicate it may not be appropriate to use the PROACT placebo patients as historical controls for mechanical thrombectomy trials.

Abstract P580: Prevalence and Natural History of Large Vessel Occlusion in Childhood Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Wilmot Bonnet ◽  
Michael M Dowling ◽  
Patricia Plumb
Keyword(s):  
Ischemic Stroke ◽  
Natural History ◽  
Acute Ischemic Stroke ◽  
Chart Review ◽  
Pediatric Population ◽  
Adult Population ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
History Of

Introduction: Many studies have reported endovascular revascularization therapy (ERT) in children with Childhood Acute Ischemic Stroke (CAIS). With the recent expansion of thrombectomy windows via DAWN/DEFUSE3, more pediatric stroke patients are likely to be potential candidates for intervention. The prevalence of Large Vessel Occlusion (LVO) in the adult population is 25-33% however the prevalence and natural history of LVO in the pediatric population have not yet been described. Methods: This is an IRB approved single center observational study by retrospective chart review of all CAIS who presented acutely to our center from 2004 to 2019. Components of Chart review: Vessel involvement, Mortality/dependency, PSOM and MRS, Etiology, Intervention/Time window of presentation/eligibility for DAWN/DEFUSE, treatment (thrombolysis, ERT), and outcome. Results: 48/218 (22%) of patients with CAIS had an acute presentation consistent with LVO (95% CI 16.7-28.1%). Of the patients with LVO, 23 (46%) were due to large vessel arteriopathy, 15(30%) were cardioembolic, 4 had a hypercoagulable state and 7 were cryptogenic. Ages ranged from day of life 1 to 18 years. 6 (12%) patients died within 2 years of LVO (3 of stroke, 3 from other causes). 5 of the 218 patients reviewed received thrombolysis, with 4/48 LVO patients received thrombolytics. 5/49 LVO patients underwent ERT (4 with at least TICI 2A reperfusion). Average age of LVO patients 14.2 years. PSOM/ comparative outcome data collection is ongoing. Conclusion: Prevalence of LVO has not yet been described in the pediatric population. At our center, 22.4% of CAIS patients had imaging consistent with large vessel occlusion at presentation. This rate is close to that of the adult population (25-33%). Many children have tolerated ERT with good outcomes. Time windows may be less applicable in children given presence of better collaterals and good cardiovascular function. More data is needed regarding the use of advanced imaging modalities for patient stratification in acute neurovascular intervention. Different inclusion criteria may be necessary given improved outcomes among children without intervention.

'Drip-and-ship' intravenous thrombolysis and outcomes for large vessel occlusion thrombectomy candidates in a hub-and-spoke telestroke model

2021 ◽  
pp. neurintsurg-2021-017819
Author(s):  
Robert W Regenhardt ◽  
Joseph A Rosenthal ◽  
Amine Awad ◽  
Juan Carlos Martinez-Gutierrez ◽  
Neal M Nolan ◽  
...  
Keyword(s):  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Hub And Spoke ◽  
Endovascular Thrombectomy ◽  
Increased Risk ◽  
Intravenous Alteplase ◽  
Model Versus

BackgroundRandomized trials have not demonstrated benefit from intravenous thrombolysis among patients undergoing endovascular thrombectomy (EVT). However, these trials included primarily patients presenting directly to an EVT capable hub center. We sought to study outcomes for EVT candidates who presented to spoke hospitals and were subsequently transferred for EVT consideration, comparing those administered alteplase at spokes (i.e., ‘drip-and-ship’ model) versus those not.MethodsConsecutive EVT candidates presenting to 25 spokes from 2018 to 2020 with pre-transfer CT angiography defined emergent large vessel occlusion and Alberta Stroke Program CT score ≥6 were identified from a prospectively maintained Telestroke database. Outcomes of interest included adequate reperfusion (Thrombolysis in Cerebral Infarction (TICI) 2b–3), intracerebral hemorrhage (ICH), discharge functional independence (modified Rankin Scale (mRS) ≤2), and 90 day functional independence.ResultsAmong 258 patients, median age was 70 years (IQR 60–81), median National Institutes of Health Stroke Scale (NIHSS) score was 13 (6-19), and 50% were women. Ninety-eight (38%) were treated with alteplase at spokes and 113 (44%) underwent EVT at the hub. Spoke alteplase use independently increased the odds of discharge mRS ≤2 (adjusted OR 2.43, 95% CI 1.08 to 5.46, p=0.03) and 90 day mRS ≤2 (adjusted OR 3.45, 95% CI 1.65 to 7.22, p=0.001), even when controlling for last known well, NIHSS, and EVT; it was not associated with an increased risk of ICH (OR 1.04, 95% CI 0.39 to 2.78, p=0.94), and there was a trend toward association with greater TICI 2b–3 (OR 3.59, 95% CI 0.94 to 13.70, p=0.06).ConclusionsIntravenous alteplase at spoke hospitals may improve discharge and 90 day mRS and should not be withheld from EVT eligible patients who first present at alteplase capable spoke hospitals that do not perform EVT. Additional studies are warranted to confirm and further explore these benefits.

scholarly journals Analysis of Frailty in Geriatric Patients as a Prognostic Factor in Endovascular Treated Patients with Large Vessel Occlusion Strokes

2021 ◽  
Vol 10 (10) ◽  
pp. 2171
Author(s):  
Marlena Schnieder ◽  
Mathias Bähr ◽  
Mareike Kirsch ◽  
Ilko Maier ◽  
Daniel Behme ◽  
...  
Keyword(s):  
Adverse Outcomes ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Health Care Outcomes ◽  
Increased Risk ◽  
Observational Cohort ◽  
Care Outcomes ◽  
The Impact ◽  
Retrospective Observational Cohort Study

Frailty is associated with an increased risk of adverse health-care outcomes in elderly patients. The Hospital Frailty Risk Score (HFRS) has been developed and proven to be capable of identifying patients which are at high risk of adverse outcomes. We aimed to investigate whether frail patients also face adverse outcomes after experiencing an endovascular treated large vessel occlusion stroke (LVOS). In this retrospective observational cohort study, we analyzed patients ≥ 65 years that were admitted during 2015–2019 with LVOS and endovascular treatment. Primary outcomes were mortality and the modified Rankin Scale (mRS) after three months. Regression models were used to determine the impact of frailty. A total of 318 patients were included in the cohort. The median HFRS was 1.6 (IQR 4.8). A total of 238 (75.1%) patients fulfilled the criteria for a low-frailty risk with a HFRS < 5.72 (22.7%) for moderate-frailty risk with an HFRS from 5–15 and 7 (2.2%) patients for a high-frailty risk. Multivariate regression analyses revealed that the HFRS was associated with an increased mortality after 90 days (CI (95%) 1.001 to 1.236; OR 1.112) and a worse mRS (CI (95%) 1.004 to 1.270; OR 1.129). We identified frailty as an impact factor on functional outcome and mortality in patients undergoing thrombectomy in LVOS.

scholarly journals Implications of limiting mechanical thrombectomy to patients with emergent large vessel occlusion meeting top tier evidence criteria

2016 ◽  
Vol 9 (3) ◽  
pp. 225-228 ◽  
Author(s):  
Rohini Bhole ◽  
Nitin Goyal ◽  
Katherine Nearing ◽  
Andrey Belayev ◽  
Vinodh T Doss ◽  
...  
Keyword(s):  
Mechanical Thrombectomy ◽  
Time Window ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Strict Adherence ◽  
Nihss Score ◽  
Neurological Improvement ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Increased Risk

BackgroundRecent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence would have impacted treatment numbers and outcomes in a cohort of patients from a comprehensive stroke center.MethodsA retrospective observational study was conducted using consecutive emergent endovascular patients. Mechanical thrombectomy (MT) was performed with stent retrievers or large bore clot aspiration catheters. Procedural outcomes were compared between patients meeting, and those failing to meet, top tier evidence criteria.Results126 patients receiving MT from January 2012 to June 2015 were included (age 31–89 years, National Institutes of Health Stroke Scale (NIHSS) score 2–38); 62 (49%) patients would have been excluded if top tier criteria were upheld: pretreatment NIHSS score <6 (10%), Alberta Stroke Program Early CT score <6 (6.5%), premorbid modified Rankin Scale (mRS) score ≥2 (27%), M2 occlusion (10%), posterior circulation (32%), symptom to groin puncture >360 min (58%). 26 (42%) subjects had more than one top tier exclusion. Symptomatic intracerebral hemorrhage (sICH) and systemic hemorrhage rates were similar between the groups. 3 month mortality was 45% in those lacking top tier evidence compared with 26% (p=0.044), and 3 month mRS score 0–2 was 33% versus 46%, respectively (NS). After adjusting for potential confounders, top tier treatment was not associated with neurological improvement during hospitalization (β −8.2; 95% CI −24.6 to −8.2; p=0.321), 3 month mortality (OR=0.38; 95% CI 0.08 to 1.41), or 3 month favorable mRS (OR=0.97; 95% CI 0.28 to 3.35).ConclusionsOur study showed that with strict adherence to top tier evidence criteria, half of patients may not be considered for MT. Our data indicate no increased risk of sICH and a potentially higher mortality that is largely due to treatment of patients with basilar occlusions and those treated at an extended time window. Despite this, good functional recovery is possible, and consideration of MT in patients not meeting top tier evidence criteria may be warranted.

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