Malignant infarction after endovascular treatment: Incidence and prediction

2021 ◽  
pp. 174749302110062
Author(s):  
Marie Louise E Bernsen ◽  
Frans Kauw ◽  
Jasper M Martens ◽  
Aad van der Lugt ◽  
Lonneke SF Yo ◽  
...  
Keyword(s):  
Risk Factors ◽  
Prediction Model ◽  
Endovascular Treatment ◽  
Characteristic Curve ◽  
Binary Logistic Regression Model ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Model Combining ◽  
Malignant Infarction ◽  
Lemeshow Test

Background Early prediction of malignant infarction may guide treatment decisions. For patients who received endovascular treatment, the risk of malignant infarction is unknown and risk factors are unrevealed. Aims The objective of this study is to estimate the incidence of malignant infarction after endovascular treatment in patients with an occlusion of the anterior circulation, to identify independent risk factors, and to establish a model for prediction. Methods We analyzed patients who received endovascular treatment for a large vessel occlusion in the anterior circulation within 6.5 h after symptom onset, included in the Dutch MR CLEAN Registry between March 2014 and June 2016. We compared patients with and without malignant infarction. Candidate predictors were incorporated in a multivariable binary logistic regression model. The final prediction model was established using backward elimination. Discrimination and calibration were evaluated with the area under the receiver operating characteristic curve (AUROC) and the Hosmer-Lemeshow test. Results Of 1445 patients, 82 (6%) developed malignant infarction. Independent predictors were lower age, higher National Institutes of Health Stroke Scale (NIHSS), lower alberta stroke program early CT score (ASPECTS), internal carotid artery occlusion, lower collateral score, longer times from onset to groin puncture, and unsuccessful reperfusion. The AUROC of a prediction model combining these features was 0.83 (95% confidence interval (CI): 0.79–0.88) and the Hosmer-Lemeshow test indicated appropriate calibration (P = 0.937). Conclusion The risk of malignant infarction after endovascular treatment started within 6.5 h of stroke onset is approximately 6%. Successful reperfusion decreases the risk. A prediction model combining easily retrievable measures of age, ASPECTS, collateral status, and reperfusion shows good discrimination between patients who will develop malignant infarction and those who will not.

scholarly journals Outcome of endovascular treatment within and beyond 6 h without perfusion software

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Zhen Jing ◽  
Hao Li ◽  
Shengming Huang ◽  
Min Guan ◽  
Yongxin Li ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
General Anesthesia ◽  
Acute Ischemic Stroke ◽  
Clinical Outcomes ◽  
Symptom Onset ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Group A ◽  
Group B

AbstractEndovascular treatment (EVT) has been accepted as the standard of care for patients with acute ischemic stroke. The aim of the present study was to compare clinical outcomes of patients who received EVT within and beyond 6 h from symptom onset to groin puncture without perfusion software in Guangdong district, China. Between March 2017 and May 2018, acute ischemic stroke patients who received EVT from 6 comprehensive stroke centers, were enrolled into the registry study. In this subgroup study, we included all patients who had acute proximal large vessel occlusion in the anterior circulation. The demographic, clinical and neuroimaging data were collected from each center. A total of 192 patients were included in this subgroup study. They were divided into two groups: group A (n = 125), within 6 h; group B (n = 67), 6–24 h from symptom onset to groin puncture. There were no substantial differences between these two groups in terms of 90 days favorable outcome (modified Rankin scale [mRS] ≤ 2, P = 0.051) and mortality (P = 0.083), and the risk of symptomatic intracranial hemorrhage at 24 h (P = 0.425). The NIHSS (median 16, IQR12-20, group A; median 12, IQR8-18, group B; P = 0.009) and ASPECTS (median 10, IQR8-10, group A; median 9, IQR8-10, group B; P = 0.034) at baseline were higher in group A. The anesthesia method (general anesthesia, 21.3%, group A vs. 1.5% group B, P = 0.001) were also statistically different between the two groups. The NIHSS and ASPECTS were higher, and general anesthesia was also more widely used in group A. Clinical outcomes were not significantly different within 6 h versus 6–24 h from symptom onset to groin puncture in this real world study.

Predictors of parenchymal hemorrhage after endovascular treatment in acute ischemic stroke: data from ANGEL-ACT Registry

2022 ◽  
pp. neurintsurg-2021-018292
Author(s):  
Dapeng Sun ◽  
Baixue Jia ◽  
Xu Tong ◽  
Peter Kan ◽  
Xiaochuan Huo ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Multivariable Analysis ◽  
Serum Glucose ◽  
Chinese Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Atherosclerotic Stenosis

BackgroundParenchymal hemorrhage (PH) is a troublesome complication after endovascular treatment (EVT).ObjectiveTo investigate the incidence, independent predictors, and clinical impact of PH after EVT in patients with acute ischemic stroke (AIS) due to anterior circulation large vessel occlusion (LVO).MethodsSubjects were selected from the ANGEL-ACT Registry. PH was diagnosed according to the European Collaborative Acute Stroke Study classification. Logistic regression analyses were performed to determine the independent predictors of PH, as well as the association between PH and 90-day functional outcome assessed by modified Rankin Scale (mRS) score.ResultsOf the 1227 enrolled patients, 147 (12.0%) were diagnosed with PH within 12–36 hours after EVT. On multivariable analysis, low admission Alberta Stroke Program Early CT score (ASPECTS)(adjusted OR (aOR)=1.13, 95% CI 1.02 to 1.26, p=0.020), serum glucose >7 mmol/L (aOR=1.82, 95% CI 1.16 to 2.84, p=0.009), and neutrophil-to-lymphocyte ratio (NLR; aOR=1.05, 95% CI 1.02 to 1.09, p=0.005) were associated with a high risk of PH, while underlying intracranial atherosclerotic stenosis (ICAS; aOR=0.42, 95% CI 0.22 to 0.81, p=0.009) and intracranial angioplasty/stenting (aOR=0.37, 95% CI 0.15 to 0.93, p=0.035) were associated with a low risk of PH. Furthermore, patients with PH were associated with a shift towards to worse functional outcome (mRS score 4 vs 3, adjusted common OR (acOR)=2.27, 95% CI 1.53 to 3.38, p<0.001).ConclusionsIn Chinese patients with AIS caused by anterior circulation LVO, the risk of PH was positively associated with low admission ASPECTS, serum glucose >7 mmol/L, and NLR, but negatively related to underlying ICAS and intracranial angioplasty/stenting.Trial registration numberNCT03370939.

Abstract TP18: Endovascular Treatment in the Elderly with Acute Ischemic Stroke - Is it Safe in Clinical Practice?

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Thabele M Leslie-Mazwi ◽  
Syed F Ali ◽  
Sanjeeva R Onteddu ◽  
Adewumi D Amole ◽  
Mehmet S Akdol ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Hospital Mortality ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Univariate Analysis ◽  
The Elderly ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Younger Patients

Introduction: An overwhelming benefit from endovascular treatment (EVT) of acute ischemic stroke (AIS) has been shown in recent trials, making it the new evidence-based standard of care for ischemic stroke due to anterior circulation large vessel occlusion. We sought to determine usage, safety and efficacy of EVT in patients ≥80 years of age. Methods: Using GWTG stroke registry data from MGH and UAMS, we analyzed 7,505 consecutive stroke admissions from 01/2009 - 06/2016. Univariate analysis was carried out to compare AIS patients < 80 vs. those ≥ 80yr. Results: Of the total 7,505 AIS patients, 3,722 presented within 12 hr of last known well and of these 334 (334/3722, 9%) underwent EVT. The majority of AIS patients undergoing EVT were younger than 80yr of age (264/334, 79%). Of the patients who underwent EVT, younger patients were more often male, Caucasian, and had stroke risk factors of atrial fibrillation, CAD, hypertension and smokers. The two groups were similar in NIHSS, initial clinical presentation, modified pre-stroke Rankin scale of ≤ 3, and initiation of tPA as a drip and ship or stroke center front-door administration. Higher rates of pneumonia were observed in younger patients while rates of sICH were similar. Younger patients were more often discharged to home/inpatient rehabilitation facility. On univariate analysis, in-hospital mortality was significantly higher in patients ≥ 80yr [Unadj. OR 2.50 (1.24, 5.03), p=0.01], however the strength of the association attenuated substantially after adjusting for significant covariates [Adj. OR 2.34 (0.99, 5.47), p=0.05] (Table). Conclusion: Elderly stroke patients are largely excluded from clinical trials and data are limited on the effectiveness of EVT in this cohort. Our results showed that rate of sICH and adjusted in-hospital mortality was not statistically different between those < 80yr vs. ≥ 80yr. Further studies are needed to explore the functional outcome of the elderly stroke patients undergoing EVT.

scholarly journals Workflow Intervals of Endovascular Acute Stroke Therapy During On- Versus Off-Hours

Stroke ◽  
2019 ◽  
Vol 50 (10) ◽  
pp. 2842-2850 ◽  
Author(s):  
Wouter H. Hinsenveld ◽  
Inger R. de Ridder ◽  
Robert J. van Oostenbrugge ◽  
Jan A. Vos ◽  
Adrien E. Groot ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Large Vessel ◽  
Complication Rates ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Significant Difference

Background and Purpose— Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours. Methods— We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models. Results— We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar. Conclusions— Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.

Combined use of contact aspiration and the stent retriever technique versus stent retriever alone for recanalization in acute cerebral infarction: the randomized ASTER 2 study protocol

2020 ◽  
Vol 12 (5) ◽  
pp. 471-476 ◽  
Author(s):  
Bertrand Lapergue ◽  
Julien Labreuche ◽  
Raphaël Blanc ◽  
Gaultier Marnat ◽  
Arturo Consoli ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Cerebral Infarction ◽  
Endovascular Treatment ◽  
Scale Score ◽  
Stent Retriever ◽  
Large Vessel Occlusion ◽  
First Line ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Combined Use

RationaleMechanical thrombectomy (MT) using a stent retriever (SR) device is currently the recommended treatment in ischemic stroke due to anterior circulation large vessel occlusion. Combining contact aspiration (CA) with SR is a promising new treatment, although it was not found to be superior to SR alone as first-line treatment for achieving successful reperfusion.AimTo determine whether endovascular treatment combining first-line use of CA and SR is more efficient than SR alone.MethodsThe ASTER 2 clinical trial is a prospective, randomized, multicenter, open-label trial with a blinded endpoint. We included patients admitted with suspected anterior circulation ischemic stroke secondary to large vessel occlusion <8 hours from symptom onset. They were randomly allocated in a 1:1 ratio to one of two treatment groups (combined CA and SR or SR alone). In the case of failure of the assigned technique after three attempts, other adjunctive techniques were applied.Study outcomeThe primary outcome is the rate of successful/complete reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) score 2c/3) after the entire endovascular procedure. Secondary outcomes include reperfusion rates after the assigned first-line intervention alone and at the end of the procedure, procedural times, change in NIH Stroke Scale score at 24 hours, intracerebral hemorrhage at 24 hours, procedure-related serious adverse events, the modified Rankin Scale score, and all-cause mortality at 90 days and 1 year. The cost effectiveness of the two procedures will also be analyzed.DiscussionThis is the first head-to-head randomized trial to directly compare the efficacy of the combined use of CA and SR versus SR alone. This prospective trial aims to demonstrate the synergistic effects of CA and SR devices in first-line endovascular treatment.

scholarly journals Intravenous Thrombolysis Is Not Associated with Increased Time to Endovascular Treatment

2020 ◽  
Vol 49 (3) ◽  
pp. 321-327
Author(s):  
Wouter H. Hinsenveld ◽  
Inger R. de Ridder ◽  
Robert J. van Oostenbrugge ◽  
Wim H. van Zwam ◽  
Jan Albert Vos ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Intravenous Thrombolysis ◽  
Ct Imaging ◽  
Digital Subtraction ◽  
Large Vessel Occlusion ◽  
Time Intervals ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Increase Risk ◽  
Mr Clean

Background: Endovascular treatment (EVT) with or without intravenous thrombolysis (IVT) is effective and safe in is­chemic stroke caused by large vessel occlusion, but IVT might delay time to EVT or increase risk of intracranial hemorrhage (ICH). We assessed the influence of prior IVT on time to treatment and risk of ICH in patients treated with EVT. Methods: We analyzed data from the MR CLEAN Registry and included patients with an anterior circulation occlusion treated with EVT who presented directly to an intervention center, between 2014 and 2017. Primary endpoint was the door to groin time. Secondary outcomes were workflow time intervals and safety outcomes. We compared patients who received EVT only with patients who received IVT prior to EVT. Results: We included 1,427 patients directly referred to an intervention center of whom 1,023 (72%) received IVT + EVT. Adjusted door to CT imaging and door to groin time were shorter in IVT + EVT patients (difference 5.7 min [95% CI: 4.6–6.8] and 7.0 min [95% CI: 2.4–12], respectively) while CT imaging to groin time was similar between the groups. Early recanalization on digital subtraction angiography before EVT was seen more often after prior IVT (11 vs. 5.2%, aOR 2.4 [95% CI: 1.4–4.2]). Rates of symptomatic ICH were similar. Conclusion: Prior IVT did not delay door to groin times and was associated with higher rates of early recanalization, without increasing the risk of ICH. Our results do not warrant withholding IVT prior to EVT.

scholarly journals A clinical prediction model for estimating the risk of developing uveitis in patients with juvenile idiopathic arthritis

Rheumatology ◽  
2020 ◽  
Author(s):  
Joeri W van Straalen ◽  
Gabriella Giancane ◽  
Yasmine Amazrhar ◽  
Nikolay Tzaribachev ◽  
Calin Lazar ◽  
...  
Keyword(s):  
Risk Factors ◽  
Prediction Model ◽  
Protective Factor ◽  
Prediction Models ◽  
Characteristic Curve ◽  
Multivariable Analysis ◽  
Information Criterion ◽  
Logistic Regression Models ◽  
Adjusted Risk ◽  
Independent Risk Factors

Abstract Objective To build a prediction model for uveitis in children with JIA for use in current clinical practice. Methods Data from the international observational Pharmachild registry were used. Adjusted risk factors as well as predictors for JIA-associated uveitis (JIA-U) were determined using multivariable logistic regression models. The prediction model was selected based on the Akaike information criterion. Bootstrap resampling was used to adjust the final prediction model for optimism. Results JIA-U occurred in 1102 of 5529 JIA patients (19.9%). The majority of patients that developed JIA-U were female (74.1%), ANA positive (66.0%) and had oligoarthritis (59.9%). JIA-U was rarely seen in patients with systemic arthritis (0.5%) and RF positive polyarthritis (0.2%). Independent risk factors for JIA-U were ANA positivity [odds ratio (OR): 1.88 (95% CI: 1.54, 2.30)] and HLA-B27 positivity [OR: 1.48 (95% CI: 1.12, 1.95)] while older age at JIA onset was an independent protective factor [OR: 0.84 (9%% CI: 0.81, 0.87)]. On multivariable analysis, the combination of age at JIA onset [OR: 0.84 (95% CI: 0.82, 0.86)], JIA category and ANA positivity [OR: 2.02 (95% CI: 1.73, 2.36)] had the highest discriminative power among the prediction models considered (optimism-adjusted area under the receiver operating characteristic curve = 0.75). Conclusion We developed an easy to read model for individual patients with JIA to inform patients/parents on the probability of developing uveitis.

scholarly journals Construction and Evaluation of a Sepsis Risk Prediction Model for Urinary Tract Infection

2021 ◽  
Vol 8 ◽  
Author(s):  
Luming Zhang ◽  
Feng Zhang ◽  
Fengshuo Xu ◽  
Zichen Wang ◽  
Yinlong Ren ◽  
...  
Keyword(s):  
Risk Factors ◽  
Urinary Tract Infection ◽  
Urinary Tract ◽  
Tract Infection ◽  
Prediction Model ◽  
Stepwise Logistic Regression ◽  
Distribution Width ◽  
Sepsis Risk ◽  
Lemeshow Test ◽  
Independent Risk Factors

Background: Urinary tract infection (UTI) is one of the common causes of sepsis. However, nomograms predicting the sepsis risk in UTI patients have not been comprehensively researched. The goal of this study was to establish and validate a nomogram to predict the probability of sepsis in UTI patients.Methods: Patients diagnosed with UTI were extracted from the Medical Information Mart for Intensive Care III database. These patients were randomly divided into training and validation cohorts. Independent prognostic factors for UTI patients were determined using forward stepwise logistic regression. A nomogram containing these factors was established to predict the sepsis incidence in UTI patients. The validity of our nomogram model was determined using multiple indicators, including the area under the receiver operating characteristic curve (AUC), correction curve, Hosmer-Lemeshow test, integrated discrimination improvement (IDI), net reclassification improvement (NRI), and decision-curve analysis (DCA).Results: This study included 6,551 UTI patients. Stepwise regression analysis revealed that the independent risk factors for sepsis in UTI patients were congestive heart failure, diabetes, liver disease, fluid electrolyte disorders, APSIII, neutrophils, lymphocytes, red blood cell distribution width, urinary protein, urinary blood, and microorganisms. The nomogram was then constructed and validated. The AUC, NRI, IDI and DCA of the nomogram all showed better performance than traditional APSIII score. The calibration curve and Hosmer-Lemeshow test results indicate that the nomogram was well-calibrated. Improved NRI and IDI values indicate that our nomogram scoring system is superior to other commonly used ICU scoring systems. The DCA curve indicates that the DCA map of the nomogram has good clinical application ability.Conclusion: This study identified the independent risk factors of sepsis in UTI patients and used them to construct a prediction model. The present findings may provide clinical reference information for preventing sepsis in UTI patients.

scholarly journals Posterior Circulation Ischemia in the Endovascular Era

Neurology ◽  
2021 ◽  
Vol 97 (20 Supplement 2) ◽  
pp. S158-S169
Author(s):  
Roberta Novakovic-White ◽  
Juan Mario Corona ◽  
Jonathan A. White
Keyword(s):  
Risk Factors ◽  
Systematic Review ◽  
Endovascular Treatment ◽  
Ct Perfusion ◽  
Posterior Circulation ◽  
Basilar Artery Occlusion ◽  
Current Evidence ◽  
Anterior Circulation ◽  
Limb Weakness ◽  
Presenting Symptoms

Background and ObjectivesTo perform literature review of clinical, radiographic, and anatomical features of posterior circulation ischemia (PCI) and systematic review of the literature on the management of basilar artery occlusion (BAO) and associated outcomes.MethodsReview of literature was conducted to identify publications describing the risk factors, etiology, clinical presentation, and imaging for PCI. A systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement. PubMed and Ovid MEDLINE were searched from 2009 to 2020 for articles relating to management of BAO. A synthesis was compiled summarizing current evidence on management of BAO.ResultsPCI accounts for 15%–20% of strokes. Risk factors are similar to anterior circulation strokes. Dizziness (47%), unilateral limb weakness (41%), and dysarthria (31%) are the most common presenting symptoms. A noncontrast head CT will identify PCI in 21% of cases; diffusion-weighted MRI or CT perfusion increase sensitivity to 85%. Recent trials have shown endovascular therapy can achieve >80% recanalization of BAO. In select patients, 30%–60% who receive endovascular treatment can achieve favorable outcome vs without. A total of 13% achieve good outcome and there is an 86% mortality rate.DiscussionPCI can present with waxing and waning symptoms or clinical findings that overlap with stroke mimics and anterior circulation ischemia, making diagnosis more heavily dependent on imaging. Recanalization is an important predictor of improved functional outcome and survival. In this endovascular era, trials of BAO are fraught with deterrents to enrollment. Despite limitations, endovascular treatment has shown improved outcome in select patients.

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