Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke

ObjectiveTo determine the impact of endovascular therapy for large vessel occlusion stroke in patients with pre-morbid disability versus those without.MethodsWe performed a post-hoc analysis of the TREVO Stent-Retriever Acute Stroke (TRACK) Registry, which collected data on 634 consecutive stroke patients treated with the Trevo device as first-line EVT at 23 centers in the United States. We included patients with internal carotid or middle cerebral (M1/M2 segment) artery occlusions and the study exposure was patient- or caregiver-reported premorbid modified Rank Scale (mRS) ≥2 (premorbid disability, PD) versus premorbid mRS score 0-1 (no premorbid disability, NPD). The primary outcome was no accumulated disability, defined as no increase in 90-day mRS from the patient’s pre-morbid mRS.ResultsOf the 634 patients in TRACK, 407 patients were included in our cohort, of which 53/407 (13.0%) had PD. The primary outcome of no accumulated disability was achieved in 37.7% (20/53) of patients with PD and 16.7% (59/354) of patients with NPD (p<0.001), while death occurred in 39.6% (21/53) and 14.1% (50/354) (p<0.001), respectively. The adjusted odds ratio of no accumulated disability for PD patients was 5.2 (95% CI 2.4-11.4, p<0.001) compared to patients with NPD. However, the adjusted odds ratio for death in PD patients was 2.90 (95% CI 1.38-6.09, p=0.005).ConclusionsIn this study of anterior circulation acute ischemic stroke patients treated with EVT, we found that premorbid disability was associated with a higher probability of not accumulating further disability compared to patients with no premorbid disability, but also with higher probability of death.Classification of EvidenceThis study provides Class II evidence that in anterior circulation acute ischemic stroke treated with EVT, patients with premorbid disability compared to those without disability were more likely not to accumulate more disability but were more likely to die. 

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Cortical Microinfarcts Associated With Worse Outcomes in Patients With Acute Ischemic Stroke Receiving Endovascular Treatment

Stroke ◽

10.1161/strokeaha.120.030895 ◽

2020 ◽

Vol 51 (9) ◽

pp. 2742-2751

Author(s):

Yufei Wei ◽

Yuehua Pu ◽

Yuesong Pan ◽

Ximing Nie ◽

Wanying Duan ◽

...

Keyword(s):

Logistic Regression ◽

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Outcome ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Primary Outcome ◽

Large Vessel Occlusion ◽

Vessel Occlusion

Background and Purpose: We aimed to evaluate the impact of cortical microinfarcts (CMIs) on functional outcome after endovascular treatment in patients with acute ischemic stroke. Methods: In a multicenter registration study for RESCUE-RE (a registration study for Critical Care of Acute Ischemic Stroke After Recanalization), eligible patients with large vessel occlusion stroke receiving endovascular treatment, who had undergone 3T magnetic resonance imaging on admission or within 24 hours after endovascular treatment were analyzed. We evaluated the presence and numbers of CMIs with assessment of axial T1, T2-weighted images, and fluid-attenuated inversion recovery images. The primary outcome was functional dependence or death defined as modified Rankin Scale scores of 3 to 6 at 90 days. Secondary outcomes included early neurological improvement, any intracranial hemorrhage, symptomatic intracranial hemorrhage, and mortality. We investigated the independent associations of CMIs with the outcomes using multivariable logistic regression in overall patients and in subgroups. Results: Among 414 patients (enrolled from July 2018 to May 2019) included in the analyses, 96 (23.2%) patients had at least one CMI (maximum 6). Patients with CMI(s) were more likely to be functionally dependent or dead at 90 days, compared with those without (55.2% versus 37.4%; P <0.01). In multivariable logistic regression analyses, presence of CMI(s) (adjusted odds ratio, 1.78 [95% CI, 1.04−3.07]; P =0.04) and multiple CMIs (CMIs ≥2; adjusted odds ratio, 7.41 [95% CI, 2.48−22.17]; P <0.001) were independently, significantly associated with the primary outcome. There was no significant difference between subgroups in the associations between CMI presence and the primary outcome. Conclusions: Acute large vessel occlusion stroke patients receiving endovascular treatment with CMI(s) were more likely to have a poor functional outcome at 90 days, independent of patients’ characteristics. Such associations may be dose-dependent. Registration: URL: http://www.chictr.org.cn ; Unique identifier: ChiCTR1900022154.

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Abstract 151: Early Neurologic Decline in Acute Ischemic Stroke Patients Receiving Thrombolysis With Large Vessel Occlusion and Initial Mild Deficits

Stroke ◽

10.1161/str.51.suppl_1.151 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Gaurav Thakur ◽

Ciaran J Powers ◽

Shahid M Nimjee ◽

Patrick Youssef ◽

Sushil Lakhani ◽

...

Keyword(s):

Ischemic Stroke ◽

Natural History ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Intravenous Tissue Plasminogen Activator ◽

The Mean

Introduction: A quarter of ischemic stroke patients with initial mild deficits have a poor outcome. We sought to determine the rate of early neurological decline in acute ischemic stroke patients with large vessel occlusion (LVO) who presented with mild deficits. Methods: Among 1022 acute ischemic stroke patients who received intravenous tissue plasminogen activator (IVtPA) admitted to our institution from January 1, 2014 to March 31, 2019, we identified 313 (30.6%) with LVO. We defined anterior circulation LVO as M1, M2, or carotid artery terminus (ICAT). Mild deficits were defined as National Institute of Health Stroke Scale (NIHSS) ≤ 7. Data was abstracted on demographics, neuroimaging, last known well (LKW), time to IVtPA, intra-arterial therapy (IAT) revascularization, Thrombolysis in Cerebral Infarction score (TICI), clinical presentation, and outcome. Early neurologic decline was defined as NIHSS worsening of ≥ 4 points within 24 hours. Results: Among 313 patients with LVO, we identified 94 (30%) who presented with initial low NIHSS (≤ 7) due to anterior circulation LVO. We excluded 13 patients who did not have natural history data (underwent IAT with mild deficits), leaving 81 patient for analysis. The mean age was 65.8 years (range 25 to 93) and 41% were female. IVtPA time from LKW was a mean 2.5 hours (range, 0.8 to 7). LVO sites were as follows: 5 (6%) ICAT, 23 (28%) M1, and 53 (65%) M2 occlusions. Among the 81 patients, 27 (33.3%) had early neurological decline. Patients with decline were significantly older (71.2 vs 63.1 years, p=0.03). Among the 27 patients with decline, the mean change in NIHSS was 10.5 (range, 4 to 22) and 12 patients (44%) underwent rescue IAT resulting in TICI 2B (6) and TICI 3 (6) revascularization. On hospital discharge, patients with decline were less likely to be discharged home (26% vs 65%, p=0.006). Conclusions: Among LVO patients who received IVtPA, 30% present with initial mild deficits. Early neurological decline occurred in one-third of LVO patients with initial mild deficits despite receiving IVtPA, and patients with decline were less likely to be discharged home. Clinicians need to be aware of the natural history of LVO with initial mid deficits, as patients who decline would be eligible for rescue IAT in the expanded 24 hour window.

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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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Are we close to the twilight of IV thrombolysis for acute ischemic stroke patients with large vessel occlusion?

Neurology ◽

10.1212/wnl.0000000000005281 ◽

2018 ◽

Vol 90 (15) ◽

pp. 673-674

Author(s):

Emmanuel Carrera ◽

Daniel Strbian

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Stroke Patients ◽

Vessel Occlusion

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Abstract WP39: Mechanical Embolectomy for Acute Ischemic Stroke Beyond Six Hours From Symptom Onset Using Advanced MR Imaging

Stroke ◽

10.1161/str.48.suppl_1.wp39 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Ryan McTaggart ◽

Shadi Yaghi ◽

Daniel C Sacchetti ◽

Richard Haas ◽

Shawna Cutting ◽

...

Keyword(s):

Ischemic Stroke ◽

Mr Imaging ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Lesion Volume ◽

Large Artery ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Good Outcome

Background: There is very limited data on the use of advanced neuroimaging to select patients with acute ischemic stroke and large vessel occlusion for intraarterial therapy beyond 6 hours from onset. Our aim is to report the outcome of patients with acute ischemic stroke and large artery occlusion who presented beyond 6 hours from onset, had favorable MRI imaging profile, and underwent mechanical embolectomy. Methods: This is a single institution retrospective study between December 1st, 2015, and July 30 th , 2016 with acute ischemic stroke and anterior circulation large vessel occlusion (LVO) with ASPECTS of 6 or more and beyond 6 hours from symptoms onset. Favorable imaging profile was defined as 1) DWI lesion volume (as defined as apparent diffusion coefficient < 620 X 10-6 mm2/s) of 70 mL or less AND 2) Penumbra volume (as defined by volume of tissue with Tmax >6 sec) of 15 mL or greater AND 3) A mismatch ratio of 1.8 or more AND 4) Volume of tissue with perfusion lesion with Tmax > 10 sec is less than 100 mL. Good outcome was defined as a 90 day mRS≤2. Results: In the study period, 41 patients met the inclusion criteria; 22 (53.6%) had favorable imaging profile and underwent mechanical embolectomy. The median age was 75 years (59-92), 68.2% were females; the median time from last known normal to groin puncture was 684.5 minutes (range 363-1628) and the median admission NIHSS score was 17.5 (range 4-28). The rate of good outcomes in this series was similar to that in a patient level pooled meta-analysis of the recent endovascular trials (68.2% vs. 46.0%, p=0.07). The rate of good outcome matches that of the EXTEND-IA trial that selected patients using perfusion imaging (68.2% vs. 71.0%, p = 1.00). None of the patients in our cohort had symptomatic intracereberal hemorrhage. Conclusion: Advanced MR imaging may help select patients with acute ischemic stroke and anterior circulation large vessel occlusion for embolectomy beyond the treatment window used in most endovascular trials.

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

Stroke ◽

10.1161/strokeaha.119.025381 ◽

2019 ◽

Vol 50 (10) ◽

pp. 2842-2850 ◽

Cited By ~ 3

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.

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Can diffusion- and perfusion-weighted imaging alone accurately triage anterior circulation acute ischemic stroke patients to endovascular therapy?

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-013784 ◽

2018 ◽

Vol 10 (12) ◽

pp. 1132-1136 ◽

Cited By ~ 5

Author(s):

Dylan N Wolman ◽

Michael Iv ◽

Max Wintermark ◽

Gregory Zaharchuk ◽

Michael P Marks ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Primary Outcome ◽

Outcome Measure ◽

Primary Outcome Measure ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Perfusion Weighted Imaging

Background and purposeAcute ischemic stroke (AIS) patients who benefit from endovascular treatment have a large vessel occlusion (LVO), small core infarction, and salvageable brain. We determined if diffusion-weighted imaging (DWI) and perfusion-weighted imaging (PWI) alone can correctly identify and localize anterior circulation LVO and accurately triage patients to endovascular thrombectomy (ET).Materials and methodsThis retrospective cohort study included patients undergoing MRI for the evaluation of AIS symptoms. DWI and PWI images alone were anonymized and scored for cerebral infarction, LVO presence and LVO location, DWI-PWI mismatch, and ET candidacy. Readers were blinded to clinical data. The primary outcome measure was accurate ET triage. Secondary outcomes were detection of LVO and LVO location.ResultsTwo hundred and nineteen patients were included. Seventy-three patients (33%) underwent endovascular AIS treatment. Readers correctly and concordantly triaged 70 of 73 patients (96%) to ET (κ=0.938; P=0.855) and correctly excluded 143 of 146 patients (98%; P=0.942). DWI and PWI alone had a 95.9% sensitivity and a 98.4% specificity for accurate endovascular triage. LVO were accurately localized to the ICA/M1 segment in 65 of 68 patients (96%; κ=0.922; P=0.817) and the M2 segment in 18 of 20 patients (90%; κ=0.830; P=0.529).ConclusionAIS patients with anterior circulation LVO are accurately identified using DWI and PWI alone, and LVO location may be correctly inferred from PWI. MRA omission may be considered to expedite AIS triage in hyperacute scenarios or may confidently supplant non-diagnostic or artifact-limited MRA.

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