Low Hypoperfusion Intensity Ratio Is Associated with a Favorable Outcome Even in Large Ischemic Core and Delayed Recanalization Time

In ischemic brain tissue, hypoperfusion severity can be assessed using the hypoperfusion intensity ratio (HIR). We evaluated the link between HIR and clinical outcomes after successful recanalization by endovascular treatment. We retrospectively reviewed 162 consecutive patients who underwent endovascular treatment for intracranial large vessel occlusion. The HIR was calculated using an automated software program, with initial computed tomography perfusion images. The HIR was compared between patients with and without favorable outcomes. To observe the modifying effect of the HIR on the well-known major outcome determinants, regression analyses were performed in the low and high HIR groups. The median HIR value was significantly lower in patients with a favorable outcome, with an optimal cut-off point of 0.54. The HIR was an independent factor for a favorable outcome in a specific multivariable model and was significantly correlated with the Alberta Stroke Program Early Computed Tomography Score (ASPECTS). In contrast to the high HIR group, the low HIR group showed that ASPECTS and onset-to-recanalization time were not independently associated with a favorable outcome. Finally, the low HIR group had a more favorable outcome even in cases with an unfavorable ASPECTS and onset-to-recanalization time. The HIR could be useful in predicting outcomes after successful recanalization.

Download Full-text

Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery

Stroke: Vascular and Interventional Neurology ◽

10.1161/svin.121.000115 ◽

2021 ◽

Author(s):

Mohamad Abdalkader ◽

Anurag Sahoo ◽

Adam A. Dmytriw ◽

Waleed Brinjikji ◽

Guilherme Dabus ◽

...

Keyword(s):

Computed Tomography ◽

Endovascular Treatment ◽

Cerebral Artery ◽

Computed Tomography Angiography ◽

Mechanical Thrombectomy ◽

Posterior Cerebral Artery ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion

Abstract BACKGROUND Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety, and outcome of mechanical thrombectomy in acute FPCA occlusions. METHODS We performed a multicenter retrospective review of consecutive patients who underwent mechanical thrombectomy of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure computed tomography angiography or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different large vessel occlusion. Demographics, clinical presentation, imaging findings, endovascular treatment, and outcome were reviewed. RESULTS There were 25 patients with acute FPCA occlusion who underwent mechanical thrombectomy, distributed across 14 centers. Median National Institutes of Health Stroke Scale on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial computed tomography angiography in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. Thrombolysis in cerebral infarction 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intraprocedural complications. At 90 days, 48% (12/25) were functionally independent as defined by modified Rankin scale≤2. CONCLUSIONS Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the FPCA in patients presenting with anterior circulation stroke syndrome and patent anterior circulation. Novelty and significance This is the first multicenter study showing that thrombectomy of FPCA occlusion is feasible and safe.

Download Full-text

Abstract T MP12: Predictors Of Angiographic Collaterals In Patients Undergoing Intra-arterial Therapy For Acute Ischemic Stroke

Stroke ◽

10.1161/str.46.suppl_1.tmp12 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Seby John ◽

Joao Gomes ◽

Ken Uchino ◽

Dolora Wisco ◽

Gabor Toth ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Infarct Volume ◽

Multivariable Logistic Regression Analysis ◽

Collateral Flow ◽

Vessel Occlusion ◽

Multiple Endpoints ◽

Ischemic Brain ◽

Improved Outcomes ◽

Ischemic Brain Tissue

Introduction: Greater degree of collaterals to ischemic brain tissue from large vessel occlusion has been correlated to multiple endpoints including improved outcomes, improved recanalization and smaller infarct volume. The predictors of collateral circulation are poorly understood with inconsistencies in previous studies. Methods: Retrospective study from 1/07-12/12 of AIS patients who underwent IAT for ICA/M1 occlusions with TICI 0/1 flow was conducted. Baseline characteristics and treatment times were collected. Collaterals were graded using the angiographic ASITN collateral-flow grading system. Collateral were grouped into "good collaterals” (GC) for grades 3 and 4, and "poor collaterals" (PC) for grades 0, 1 and 2. Results: ASITN grading was available in 180 patients including 32 (18%) with GC and 148 (82%) with PC. Baseline demographics of all patients and each group are outlined in Table 1, with significant differences in baseline CT ASPECTS score and IV tPA administration. Multivariable logistic regression analysis demonstrated that female sex, CT ASPECTS and time to first angiographic run were the only independent predictors of GC. Conclusions: We have confirmed previous reports that GC is associated with small infarct volume, which corresponds to higher CT ASPECTS score. Odds of GC were 5.7 times in females compared to males, which is inconsistent with previous literature. Previously demonstrated association of hypertension, high admission blood pressure and high NIHSS with lesser collaterals was not seen in our study. Since collaterals affect outcomes in acute ischemic stroke, further studies of predictors of good collaterals are needed.

Download Full-text

Computed Tomography Perfusion After Thrombectomy

Stroke ◽

10.1161/strokeaha.120.029212 ◽

2020 ◽

Vol 51 (6) ◽

pp. 1736-1742

Author(s):

Marta Rubiera ◽

Alvaro Garcia-Tornel ◽

Marta Olivé-Gadea ◽

Daniel Campos ◽

Manuel Requena ◽

...

Keyword(s):

Computed Tomography ◽

Endovascular Treatment ◽

Scale Score ◽

Interquartile Range ◽

National Institutes Of Health ◽

Favorable Outcome ◽

Modified Rankin Scale ◽

Computed Tomography Perfusion ◽

Median Tmax ◽

Delayed Recovery

Background and Purpose— Despite recanalization, almost 50% of patients undergoing endovascular treatment (EVT) experience poor outcome. We aim to evaluate the value of computed tomography perfusion as immediate outcome predictor postendovascular treatment. Methods— Consecutive patients receiving endovascular treatment who achieved recanalization (modified Thrombolysis in Cerebral Ischemia [mTICI] 2a-3) underwent computed tomography perfusion within 30 minutes from recanalization (CTPpost). Hypoperfusion was defined as the Tmax>6 second volume; hyperperfusion as visually increased cerebral blood flow/cerebral blood volume with reduced Tmax compared with unaffected hemisphere. Dramatic clinical recovery (DCR) was defined as 24-hour National Institutes of Health Stroke Scale score ≤2 or ≥8 points drop. Delayed recovery was defined as no-DCR with favorable outcome (modified Rankin Scale score 0–2) at 3 months. Results— We included 151 patients: median National Institutes of Health Stroke Scale score 16 (interquartile range, 10–21), median admission ASPECTS 9 (interquartile range, 8–10). Final recanalization was the following: mTICI2a 11 (7.3%), mTICI2b 46 (30.5%), and mTICI3 94 (62.3%). On CTPpost, 80 (52.9%) patients showed hypoperfusion (median Tmax>6 seconds: 4 cc [0–25]) and 32 (21.2%) hyperperfusion. There was an association between final TICI and CTPpost hypoperfusion(median Tmax>6: 91 [56–117], 15 [0–37.5], and 0 [0–7] cc, for mTICI 2a, 2b, and 3, respectively, P <0.01). Smaller hypoperfusion volumes on CTPpost were observed in patients with DCR (0 cc [0–13] versus non-DCR 8 cc [0–56]; P <0.01) or favorable outcome (modified Rankin Scale score 0–2: 0 cc [0–13] versus 7 [0–56] cc; P <0.01). No associations were detected with hyperperfusion pattern. An hypoperfusion volume <3.5 cc emerged as independent predictor of DCR (OR, 4.1 [95% CI, 2.0–8.3]; P <0.01) and 3 months favorable outcome (OR, 3.5 [95% CI, 1.6–7.8]; P <0.01). Conclusions— Hypoperfusion on CTPpost constitutes an immediate accurate surrogate marker of success after endovascular treatment and identifies those patients with delayed recovery and favorable outcome.

Download Full-text

Value of cone beam computed tomography to evaluate complication of intracranial haemorrhage in endovascular treatment (evt): a case report

Journal Of Cardiovascular, Neurovascular & Stroke ◽

10.32896/cvns.v1n1.16-18 ◽

2019 ◽

Vol 1 (1) ◽

pp. 16-18 ◽

Cited By ~ 1

Author(s):

Norafida Bahari ◽

Nik Azuan Nik Ismail ◽

Jegan Thanabalan ◽

Ahmad Sobri Muda

Keyword(s):

Computed Tomography ◽

Arteriovenous Malformation ◽

Endovascular Treatment ◽

Cone Beam Computed Tomography ◽

Diagnostic Value ◽

Cone Beam ◽

Brain Arteriovenous Malformation ◽

Embolic Materials

In this article, we evaluate the effectiveness of Cone Beam Computed Tomography, through a case study, in assessing the complication of intracranial bleeding during an endovascular treatment of brain arteriovenous malformation when compared to Multislice-Detector Computed Tomography performed immediately after the procedure. The image quality of Cone Beam Computed Tomography has enough diagnostic value in differentiating between haemorrhage, embolic materials and the arteriovenous malformation nidus to facilitate physicians to decide for further management of the patient.

Download Full-text

Value of cone beam computed tomography to evaluate complication of intracranial haemorrhage in endovascular treatment (evt): a case report.

Journal Of Cardiovascular, Neurovascular & Stroke ◽

10.32896/cvns.11.16-18 ◽

2019 ◽

pp. 16-18

Author(s):

Norafida Bahari ◽

NikAzuan Nik Ismail ◽

Jegan Thanabalan ◽

Ahmad Sobri Muda

Keyword(s):

Computed Tomography ◽

Arteriovenous Malformation ◽

Endovascular Treatment ◽

Cone Beam Computed Tomography ◽

Diagnostic Value ◽

Cone Beam ◽

Brain Arteriovenous Malformation ◽

Embolic Materials

Download Full-text

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

Scientific Reports ◽

10.1038/s41598-021-84857-8 ◽

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.

Download Full-text

Value of repeated imaging in patients with a stroke who are transferred for endovascular treatment

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-017050 ◽

2021 ◽

pp. neurintsurg-2020-017050

Author(s):

Laura C C van Meenen ◽

Nerea Arrarte Terreros ◽

Adrien E Groot ◽

Manon Kappelhof ◽

Ludo F M Beenen ◽

...

Keyword(s):

Endovascular Treatment ◽

Clinical Improvement ◽

Treatment Delay ◽

Clinical Deterioration ◽

Large Vessel Occlusion ◽

Intracranial Hemorrhages ◽

Vessel Occlusion ◽

Quality Outcomes ◽

Comprehensive Stroke Center ◽

Stroke Center

BackgroundPatients with a stroke who are transferred to a comprehensive stroke center for endovascular treatment (EVT) often undergo repeated neuroimaging prior to EVT.ObjectiveTo evaluate the yield of repeating imaging and its effect on treatment times.MethodsWe included adult patients with a large vessel occlusion (LVO) stroke who were referred to our hospital for EVT by primary stroke centers (2016–2019). We excluded patients who underwent repeated imaging because primary imaging was unavailable, incomplete, or of insufficient quality. Outcomes included treatment times and repeated imaging findings.ResultsOf 677 transferred LVO stroke, 551 were included. Imaging was repeated in 165/551 patients (30%), mostly because of clinical improvement (86/165 (52%)) or deterioration (40/165 (24%)). Patients who underwent repeated imaging had higher door-to-groin-times than patients without repeated imaging (median 43 vs 27 min, adjusted time difference: 20 min, 95% CI 15 to 25). Among patients who underwent repeated imaging because of clinical improvement, the LVO had resolved in 50/86 (58%). In patients with clinical deterioration, repeated imaging led to refrainment from EVT in 3/40 (8%). No symptomatic intracranial hemorrhages (sICH) were identified. Ultimately, 75/165 (45%) of patients with repeated imaging underwent EVT compared with 326/386 (84%) of patients without repeated imaging (p<0.01).ConclusionsNeuroimaging was repeated in 30% of patients with an LVO stroke and resulted in a median treatment delay of 20 minutes. In patients with clinical deterioration, no sICH were detected and repeated imaging rarely changed the indication for EVT. However, in more than half of patients with clinical improvement, the LVO had resolved, resulting in refrainment from EVT.

Download Full-text

Quantified health and cost effects of faster endovascular treatment for large vessel ischemic stroke patients in the Netherlands

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2020-017017 ◽

2021 ◽

pp. neurintsurg-2020-017017

Author(s):

Henk van Voorst ◽

Wolfgang G Kunz ◽

Lucie A van den Berg ◽

Manon Kappelhof ◽

Floor M E Pinckaers ◽

...

Keyword(s):

Endovascular Treatment ◽

Healthcare Costs ◽

Large Vessel ◽

Secondary Outcome ◽

Vessel Occlusion ◽

Time To Treatment ◽

Stroke Population ◽

Life Years ◽

Mr Clean

BackgroundThe effectiveness of endovascular treatment (EVT) for large vessel occlusion (LVO) stroke severely depends on time to treatment. However, it remains unclear what the value of faster treatment is in the years after index stroke. The aim of this study was to quantify the value of faster EVT in terms of health and healthcare costs for the Dutch LVO stroke population.MethodsA Markov model was used to simulate 5-year follow-up functional outcome, measured with the modified Rankin Scale (mRS), of 69-year-old LVO patients. Post-treatment mRS was extracted from the MR CLEAN Registry (n=2892): costs per unit of time and Quality-Adjusted Life Years (QALYs) per mRS sub-score were retrieved from follow-up data of the MR CLEAN trial (n=500). Net Monetary Benefit (NMB) at a willingness to pay of €80 000 per QALY was reported as primary outcome, and secondary outcome measures were days of disability-free life gained and costs.ResultsEVT administered 1 min faster resulted in a median NMB of €309 (IQR: 226;389), 1.3 days of additional disability-free life (IQR: 1.0;1.6), while cumulative costs remained largely unchanged (median: -€15, IQR: −65;33) over a 5-year follow-up period. As costs over the follow-up period remained stable while QALYs decreased with longer time to treatment, which this results in a near-linear decrease of NMB. Since patients with faster EVT lived longer, they incurred more healthcare costs.ConclusionOne-minute faster EVT increases QALYs while cumulative costs remain largely unaffected. Therefore, faster EVT provides better value of care at no extra healthcare costs.

Download Full-text

P-002 Perceived limits of endovascular treatment for secondary medium vessel occlusion stroke

10.1136/neurintsurg-2021-snis.38 ◽

2021 ◽

Author(s):

P Cimflova ◽

R McDonough ◽

M Kappelhof ◽

J Ospel ◽

N Singh ◽

...

Keyword(s):

Endovascular Treatment ◽

Vessel Occlusion

Download Full-text

Effect of “drip-and-ship” and “drip-and-drive” on endovascular treatment of acute ischemic stroke with large vessel occlusion: a single-center retrospective study

Acta Radiologica ◽

10.1177/02841851211006897 ◽

2021 ◽

pp. 028418512110068

Author(s):

Yu Hang ◽

Zhen Yu Jia ◽

Lin Bo Zhao ◽

Yue Zhou Cao ◽

Huang Huang ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Primary Stroke Center ◽

Secondary Endpoints ◽

Comprehensive Stroke Center ◽

Stroke Center

Background Patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) were usually transferred from a primary stroke center (PSC) to a comprehensive stroke center (CSC) for endovascular treatment (drip-and-ship [DS]), while driving the doctor from a CSC to a PSC to perform a procedure is an alternative strategy (drip-and-drive [DD]). Purpose To compare the efficacy and prognosis of the two strategies. Material and Methods From February 2017 to June 2019, 62 patients with LVO received endovascular treatment via the DS and DD models and were retrospectively analyzed from the stroke alliance based on our CSC. Primary endpoint was door-to-reperfusion (DTR) time. Secondary endpoints included puncture-to-recanalization (PTR) time, modified Thrombolysis in Cerebral Infarction (mTICI) rates at the end of the procedure, and modified Rankin Scale (mRS) at 90 days. Results Forty-one patients received the DS strategy and 21 patients received the DD strategy. The DTR time was significantly longer in the DS group compared to the DD group (315.5 ± 83.8 min vs. 248.6 ± 80.0 min; P < 0.05), and PTR time was shorter (77.2 ± 35.9 min vs. 113.7 ± 69.7 min; P = 0.033) compared with the DD group. Successful recanalization (mTICI 2b/3) was achieved in 89% (36/41) of patients in the DS group and 86% (18/21) in the DD group ( P = 1.000). Favorable functional outcomes (mRS 0–2) were observed in 49% (20/41) of patients in the DS group and 71% (15/21) in the DD group at 90 days ( P = 0.089). Conclusion Compared with the DS strategy, the DD strategy showed more effective and a trend of better clinical outcomes for AIS patients with LVO.

Download Full-text