POTENTIAL PREDICTORS OF GOOD OUTCOME IN PATIENTS WITH BASELINE ASPECTS 0-4 TREATED WITH MECHANICAL THROMBECTOMY

Background: It is reported that pre-stroke cognitive impairment is associated with poor functional outcome after stroke associated with small vessel disease. However, it is not clear that pre-stroke cognitive impairment is associated with poor outcome in patients treated with mechanical thrombectomy. Method: We enrolled 127 consecutive patients treated with mechanical thrombectomy for acute ischemic stroke from December 2016 to November 2018. Pre-stroke cognitive function was evaluated using the Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). We retrospectively compared poor outcome (a score of 3 to 6 on the modified Rankin Scale at 90 days) group (n=75) with good outcome (a score of 0, 1, or 2 on the modified Rankin Scale at 90 days) group (n=52) and examined that IQCODE could be the predictor of PO. Result: IQCODE was significantly higher in poor outcome group than in good outcome group (89 vs. 82, P=0.0012). Moreover, age (77.2 years old vs. 71.6 years old, P= 0.0009), the percentage of female (42.7% vs. 17.3%, P= 0.0021), complication of hypertension (HT, 68.0% vs. 44.2%, P=0.0076), National Institutes of Health Stroke Scale (NIHSS) at admission (20 vs. 11, P<0.0001), the percentage of postoperative intracerebral hemorrhage (ICH, 33.3% vs. 15.4%, P=0.0233) were higher in poor outcome group than in good outcome group, too. However, there was no significant difference between poor outcome and good outcome groups in occlusion site (P= 0.1229), DWI-ASPECTS (P= 0.2839), the duration from onset to recanalization (P=0.4871) and other risk factors. Multivariable logistic regression analysis demonstrated that IQCODE, HT and NIHSS at admission were associated with poor outcome (P= 0.0128, P=0.0061 and P<0.0001, respectively). Conclusion: Cognitive impairment could be associated with poor outcome in patients treated with mechanical thrombectomy.

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Abstract 150: Multicenter Validation of SPOT, an Artificial Intelligence Based Tool, to Optimize Selection of Elderly Stroke Patients for Mechanical Thrombectomy - Insights From the STAR Collaboration

Stroke ◽

10.1161/str.51.suppl_1.150 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Ali M Alawieh ◽

Mohamed Baker Alawieh ◽

Fadi Zaraket ◽

Reda M Chalhoub ◽

Mohammad Anadani ◽

...

Keyword(s):

Elderly Patients ◽

Negative Predictive Value ◽

Predictive Value ◽

Mechanical Thrombectomy ◽

Characteristic Curve ◽

Linear Regression Models ◽

Good Outcome ◽

Poor Outcome ◽

Multicenter Validation ◽

Selection Of

Introduction: Mechanical thrombectomy for acute ischemic stroke (AIS) is the current standard of care based on level 1 evidence from multiple randomized controlled trials. Recently, real-world indications for mechanical thrombectomy (MT) has extended beyond the inclusion criteria used in the majority of trials including elderly patients. We have recently developed a machine-learning based tool, SPOT, to optimize selection of elderly patients for MT based on single-center data. Here, we use a large cohort of international multicenter patients who underwent MT for AIS to externally validate SPOT. Methods: Patients who underwent MT for AIS at 12 comprehensive stroke centers in the US and Europe between 01/2013 and 12/2018 were reviewed. Patients age 80 years or older were included for validation of SPOT. SPOT is designed based on a combination of decision trees and linear regression models to provide binary output of predicted good (mRS 0-2) or poor outcome (mRS 3-6) after MT. SPOT uses admission variables: age, gender, comorbidities, admission NIHSS, baseline mRS score, ASPECT score and whether IV-tPA was administered. Predicted outcome was compared to actual outcome recorded at 90-days after treatment. A receiver operating characteristic curve was used to evaluate the accuracy of SPOT, and the negative predictive value was computed. The rate of post-procedural hemorrhage and mortality were compared between patients predicted by SPOT to have good versus poor outcome. Results: A total of 3,228 patients underwent MT for AIS during the study duration, of which 647 patients were at least 80 years of age or older and were included in the study. The average age was 85±5 years, and 65% were females. The median mRS score at 90 days was 4, and 21.3% had a good outcome (mRS 0-2). Of patients predicted by SPOT to have a poor outcome, 90% had a poor outcome. The area under the ROC curve was 0.7. The mortality rate in patients predicted by SPOT to have poor outcome had twice higher mortality than those predicted to have good outcome (55% vs 27%, p<0.001). Conclusions: Based on multicenter validation, SPOT presents a clinical decision in aid in assisting for exclusion of elderly patients unlikely to benefit from MT for AIS with a 90% negative predictive value.

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Predictors of Poor Outcome after Successful Mechanical Thrombectomy in Patients with Acute Anterior Circulation Stroke

Journal of Clinical Interventional Radiology ISVIR ◽

10.1055/s-0037-1612600 ◽

2017 ◽

Vol 01 (03) ◽

pp. 139-143 ◽

Cited By ~ 2

Author(s):

Yosuke Tajima ◽

Michihiro Hayasaka ◽

Koichi Ebihara ◽

Masaaki Kubota ◽

Sumio Suda

Keyword(s):

Clinical Outcome ◽

Cerebral Artery ◽

Mechanical Thrombectomy ◽

Infarct Volume ◽

Complete Revascularization ◽

Anterior Circulation ◽

Clinical Imaging ◽

Good Outcome ◽

Poor Outcome ◽

Favorable Clinical Outcome

AbstractSuccessful revascularization is one of the main predictors of a favorable clinical outcome after mechanical thrombectomy. However, even if mechanical thrombectomy is successful, some patients have a poor clinical outcome. This study aimed to investigate the clinical, imaging, and procedural factors that are predictive of poor clinical outcomes despite successful revascularization after mechanical thrombectomy in patients with acute anterior circulation stroke. The authors evaluated 69 consecutive patients (mean age, 74.6 years, 29 women) who presented with acute ischemic stroke due to internal cerebral artery or middle cerebral artery occlusions and who were successfully treated with mechanical thrombectomy between July 2014 and November 2016. A good outcome was defined as a modified Rankin Scale score of 0 to 2 at 3 months after treatment. The associations between the clinical, imaging, and procedural factors and poor outcome were evaluated using logistic regression analyses. Using multivariate analyses, the authors found that the preoperative National Institute of Health Stroke Scale (NIHSS) score (odds ratio [OR], 1.152; 95% confidence interval [CI], 1.004–1.325; p = 0.028), the diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) (OR, 0.604; 95% CI, 0.412–0.882; p = 0.003), and a Thrombolysis in Cerebral Infarction (TICI) 2b classification (OR, 4.521; 95% CI, 1.140–17.885; p = 0.026) were independent predictors of poor outcome. Complete revascularization to reduce the infarct volume should be performed, especially in patients with a high DWI-ASPECTS, to increase the likelihood of a good outcome.

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Can early neurological improvement after mechanical thrombectomy be used as a surrogate for final stroke outcome?

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2018-014332 ◽

2018 ◽

Vol 11 (5) ◽

pp. 450-454 ◽

Cited By ~ 7

Author(s):

Sebastien Soize ◽

Guillaume Fabre ◽

Matthias Gawlitza ◽

Isabelle Serre ◽

Serge Bakchine ◽

...

Keyword(s):

Sensitivity And Specificity ◽

Mechanical Thrombectomy ◽

Characteristic Curve ◽

Optimal Threshold ◽

Future Research ◽

Nihss Score ◽

Neurological Improvement ◽

Good Outcome ◽

Optimal Thresholds ◽

Definition Of

Background and purposeWe aimed to identify the best definition of early neurological improvement (ENI) at 2 and 24 hours after mechanical thrombectomy (MT) and determine its ability to predict a good functional outcome at 3 months.MethodsThis retrospective analysis was based on a prospectively collected registry of patients treated by MT for ischemic stroke from May 2010 to March 2017. We included patients treated with stent-retrievers with National Institute of Health Stroke Scale (NIHSS) score before treatment and at 2 and/or 24 hours after treatment and modified Rankin Score (mRS) at 3 months. Receiver operating characteristic curve analysis was performed to estimate optimal thresholds for ENI at 2 and 24 hours. The relationship between optimal ENI definitions and good outcome at 3 months (mRS 0–2) was assessed by logistic regression.ResultsThe analysis included 246 patients. At 2 hours, the optimal threshold to predict a good outcome at 3 months was improvementin the NIHSS score of >1 point (AUC 0.83,95% CI 0.77 to 0.87), with sensitivity and specificity 78.3% (62.2–85.7%) and 84.6% (77.2–90.3%), respectively, and OR 12.67 (95% CI 4.69 to 31.10, p<0.0001). At 24 hours, the optimal threshold was an improvementin the NIHSS score of >4 points (AUC 0.93, 95% CI 0.89 to 0.96), with sensitivity and specificity 93.8% (87.7–97.5%) and 83.2% (75.7–89.2%), respectively, and OR 391.32 (95% CI 44.43 to 3448.35, p<0.0001).ConclusionsENI 24 hours after thrombectomy appears to be a straightforward surrogate of long-term endpoints and may have value in future research.

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Day 1 Extracranial Internal Carotid Artery Patency Is Associated With Good Outcome After Mechanical Thrombectomy for Tandem Occlusion

Stroke ◽

10.1161/strokeaha.118.022495 ◽

2018 ◽

Vol 49 (10) ◽

pp. 2520-2522 ◽

Cited By ~ 4

Author(s):

Nicolas Bricout ◽

Thomas Personnic ◽

Marc Ferrigno ◽

Julien Labreuche ◽

Laurent Estrade ◽

...

Keyword(s):

Carotid Artery ◽

Internal Carotid Artery ◽

Internal Carotid ◽

Mechanical Thrombectomy ◽

Extracranial Internal Carotid Artery ◽

Good Outcome ◽

Tandem Occlusion

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Mechanical Thrombectomy in Elderly Stroke Patients with Mild-to-Moderate Baseline Disability

Interventional Neurology ◽

10.1159/000487333 ◽

2018 ◽

Vol 7 (5) ◽

pp. 246-255 ◽

Cited By ~ 11

Author(s):

Diana E. Slawski ◽

Hisham Salahuddin ◽

Julie Shawver ◽

Cynthia L. Kenmuir ◽

Gretchen E. Tietjen ◽

...

Keyword(s):

Elderly Patients ◽

Chart Review ◽

Randomized Trials ◽

Mechanical Thrombectomy ◽

Real Life ◽

National Institutes Of Health ◽

Delayed Treatment ◽

Good Outcome ◽

Procedural Complications ◽

Baseline Characteristics

Background: The number of elderly patients suffering from ischemic stroke is rising. Randomized trials of mechanical thrombectomy (MT) generally exclude patients over the age of 80 years with baseline disability. The aim of this study was to understand the efficacy and safety of MT in elderly patients, many of whom may have baseline impairment. Methods: Between January 2015 and April 2017, 96 patients ≥80 years old who underwent MT for stroke were selected for a chart review. The data included baseline characteristics, time to treatment, the rate of revascularization, procedural complications, mortality, and 90-day good outcome defined as a modified Rankin Scale (mRS) score of 0–2 or return to baseline. Results: Of the 96 patients, 50 had mild baseline disability (mRS score 0–1) and 46 had moderate disability (mRS score 2–4). Recanalization was achieved in 84% of the patients, and the rate of symptomatic hemorrhage was 6%. At 90 days, 34% of the patients had a good outcome. There were no significant differences in good outcome between those with mild and those with moderate baseline disability (43 vs. 24%, p = 0.08), between those aged ≤85 and those aged > 85 years (40.8 vs. 26.1%, p = 0.19), and between those treated within and those treated beyond 8 h (39 vs. 20%, p = 0.1). The mortality rate was 38.5% at 90 days. The Alberta Stroke Program Early CT Score (ASPECTS) and the National Institutes of Health Stroke Scale (NIHSS) predicted good outcome regardless of baseline disability (p < 0.001 and p = 0.009, respectively). Conclusion: Advanced age, baseline disability, and delayed treatment are associated with suboptimal outcomes after MT. However, redefining good outcome to include return to baseline functioning demonstrates that one-third of this patient population benefits from MT, suggesting the real-life utility of this treatment.

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Onset to Reperfusion Time Was Not Important in Mechanical Thrombectomy for Elderly Patients: A Retrospective Multicenter Study in Tama Area, Tokyo

Cerebrovascular Diseases ◽

10.1159/000492867 ◽

2018 ◽

Vol 46 (1-2) ◽

pp. 89-96 ◽

Cited By ~ 4

Author(s):

Satoshi Koizumi ◽

Takahiro Ota ◽

Keigo Shigeta ◽

Tatsuo Amano ◽

Masayuki Ueda ◽

...

Keyword(s):

Elderly Patients ◽

Scale Score ◽

Mechanical Thrombectomy ◽

Treatment Strategies ◽

Onset Time ◽

Standard Of Care ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Factors Affecting ◽

Good Outcome

Background: Mechanical thrombectomy (MT) has become the standard of care for acute ischemic stroke with large vessel occlusion; however, evidence remains insufficient for MT for elderly patients, especially with respect to factors affecting their outcomes. Methods: This study was a retrospective analysis of a multicenter registry of MT, called Tama Registry of Acute Endovascular Thrombectomy. Patients were divided by their age into 2 groups: Nonelderly (NE; < 80) and elderly (E; ≥80). Factors related to a good outcome (modified Rankin scale score ≤2) were examined in each group. Onset to reperfusion time (OTR) was stratified into 4 categories: category 1, 0 – ≤180 min; category 2, > 180 – ≤360 min; category 3, > 360 min or onset time not identified; and category 4, effective recanalization not achievable. Results: 143 NE patients and 78 E patients were included in this study. The E group had less chance of achieving a good outcome (NE group 51%, E group 35%; p = 0.024). In the NE group, lower OTR category was an independent prognostic factor for good outcome (p = 0.037, OR = 1.09). However, in the E group, OTR category was not a significant predictor on multivariate analysis. Instead, effective recanalization (p = 0.0081, OR 1.40) and lower National Institute of Health Stroke Scale score at presentation (p = 0.0032, OR 1.02) were the independent predictors. Conclusions: In MT for elderly patients, effective recanalization improved the patients’ outcome but OTR affected less. Further studies are warranted to establish the appropriate patient selection and treatment strategies.

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A novel nomogram for predicting prognosis after mechanical thrombectomy in patients with acute ischemic stroke

Current Neurovascular Research ◽

10.2174/1567202618666211210154739 ◽

2021 ◽

Vol 18 ◽

Author(s):

Huiling Sun ◽

Feng Zhou ◽

Guoxing Zhang ◽

Jiankang Hou ◽

Yukai Liu ◽

...

Keyword(s):

Risk Factors ◽

Ischemic Stroke ◽

Blood Glucose ◽

Acute Ischemic Stroke ◽

Clinical Outcomes ◽

Mechanical Thrombectomy ◽

Bridging Therapy ◽

Anterior Circulation ◽

Interval Time ◽

Good Outcome

Background: Mounting evidence has shown that mechanical thrombectomy [MT] improves clinical outcomes for large vessel occlusions [LVOs] in patients with acute ischemic stroke [AIS] of the anterior circulation. The present study aimed to provide a comprehensive analysis of risk factors associated with clinical outcomes in AIS patients receiving MT. Methods: A total of 212 consecutive patients who underwent MT for AIS were enrolled in the present study. Clinical characteristics were recorded at admission. Two endpoints were defined according to the 3-month modified Rankin scale [mRS] score after AIS [good outcome, mRS 0-2; and death, mRS 6]. Additionally, we compared the clinical outcomes and safety of MT alone and bridging therapy in AIS patients. Results: Of the 212 patients treated with MT, 114 [53.77%] patients had a good outcome and 31 [14.62%] died. The incidence of a worse outcome after MT was significantly elevated in males and patients with high WBC counts, high admission blood glucose levels, high baseline NIHSS scores and a long interval time from groin puncture to reperfusion in AIS patients treated with MT after adjustment for covariates [P<0.05]; these risk factors were further confirmed by our constructed nomograms. In addition, we observed no significant benefit of bridging therapy compared to MT alone in AIS patients. Conclusion: Our constructed nomogram based on male sex, admission WBC, admission blood glucose, NIHSS, and the interval time from groin puncture to reperfusion predicts prognosis after mechanical thrombectomy in patients with acute ischemic stroke.

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Effect of workflow metrics on clinical outcomes of low diffusion-weighted imaging Alberta Stroke Program Early Computed Tomography Score (DWI-ASPECTS) patients subjected to mechanical thrombectomy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2019-015519 ◽

2019 ◽

Vol 12 (8) ◽

pp. 742-746

Author(s):

Pietro Panni ◽

Caterina Michelozzi ◽

Sébastien Richard ◽

Gaultier Marnat ◽

Raphaël Blanc ◽

...

Keyword(s):

Computed Tomography ◽

Clinical Outcomes ◽

Diffusion Weighted Imaging ◽

Primary Outcome ◽

Mechanical Thrombectomy ◽

Functional Independence ◽

Good Outcome ◽

Diffusion Weighted ◽

Degree Of Disability ◽

And Diffusion

BackgroundAlthough accumulating evidence has demonstrated the benefit of mechanical thrombectomy (MT) in patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS), it is still unclear how workflow metrics impact the clinical outcomes of this subgroup of patients.MethodsPatients with acute stroke and diffusion-weighted imaging (DWI) ASPECTS ≤5 at baseline, who underwent MT within 6 hours of symptoms onset, were included from a prospectively maintained national multicentric registry between January 1, 2012 to August 31, 2017. The degree of disability was assessed by the modified Rankin Scale (mRS) at 90 days. The primary outcome was functional independence defined as mRS 0 to 2 at 90 days.ResultsThe study included 291 patients with baseline DWI-ASPECTS ≤5. Good outcome was achieved in 82 (28.2%) patients, and 104 (35.7%) patients died within 90 days. Successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3) rate was 75.3%, and median onset to recanalization (OTR) time was 2 268min. Among time-related variables, OTR emerged as the strongest predictor of primary outcome (adjusted OR for every 60 min 0.59, 95% CI 0.44 to 0.77; p<0.001). mTICI 2c-3 independently predicted a good outcome (adjusted OR 1.91, 95% CI 1.004 to 3.6; p=0.049) along with age and baseline DWI-ASPECTS. Recanalization status failed to significantly impact outcome in the DWI-ASPECTS 0–3 subpopulation.ConclusionsNear complete reperfusion (mTICI 2c-3) and OTR are the strongest modifiable outcome predictors in patients with DWI-ASPECTS ≤5 treated with MT.

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Mechanical Thrombectomy Up to 24 Hours in Large Vessel Occlusions and Infarct Velocity Assessment

Journal of the American Heart Association ◽

10.1161/jaha.121.022880 ◽

2021 ◽

Author(s):

Manabu Inoue ◽

Takeshi Yoshimoto ◽

Kanta Tanaka ◽

Junpei Koge ◽

Masayuki Shiozawa ◽

...

Keyword(s):

Intracranial Hemorrhage ◽

Growth Velocity ◽

Mechanical Thrombectomy ◽

Large Vessel ◽

Late Time ◽

Modified Rankin Scale ◽

Excellent Outcome ◽

Good Outcome ◽

Perfusion Weighted Imaging ◽

Symptomatic Intracranial Hemorrhage

Background We retrospectively compared early‐ (<6 hours) versus late‐ (6–24 hours) presenting patients using perfusion‐weighted imaging selection and evaluated clinical/radiographic outcomes. Methods and Results Large vessel occlusion patients treated with mechanical thrombectomy from August 2017 to July 2020 within 24 hours of onset were retrieved from a single‐center database. Perfusion‐weighted imaging was analyzed by automated software and final infarct volume was measured semi‐automatically within 14 days. The primary end point was good outcome (modified Rankin Scale 0–2 at 90 days). Secondary end points were excellent outcome (modified Rankin Scale 0–1 at 90 days), symptomatic intracranial hemorrhage, and death. Clinical characteristics/radiological values including hypoperfusion volume and infarct growth velocity (baseline volume/onset‐to‐image time) were compared between the groups. Of 1294 patients, 118 patients were included. The median age was 74 years, baseline National Institutes of Health Stroke Scale score was 14, and core volume was 13 mL. The late‐presenting group had more female patients (67% versus 31%, respectively; P =0.001). No statistically significant differences were seen in good outcome (42% versus 53%, respectively; P =0.30), excellent outcome (26% versus 32%, respectively; P =0.51), symptomatic intracranial hemorrhage (6.5% versus 4.6%, respectively; P =0.74), and death (3.2% versus 5.7%, respectively; P =0.58) between the groups. The late‐presenting group had more atherothrombotic cerebral infarction (19% versus 6%, respectively; P =0.03), smaller hypoperfusion volume (median: 77 versus 133 mL, respectively; P =0.04), and slower infarct growth velocity (median: 0.6 versus 5.1 mL/h, respectively; P =0.03). Conclusions Patients with early‐ and late‐time windows treated with mechanical thrombectomy by automated perfusion‐weighted imaging selection have similar outcomes, comparable with those in randomized trials, but different in infarct growth velocities. Registration URL: https://www.clinicaltrials.gov ; Unique identifier: NCT02251665.

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