Faculty Opinions recommendation of Blood pressure after endovascular thrombectomy and malignant cerebral edema in large vessel occlusion stroke.

Introduction: The management and prognosis of acute ischemic stroke due to multiple large-vessel occlusion (LVO) (MLVO) are not well scrutinized. We therefore aimed to elucidate the differences in patient characteristics and prognosis of MLVO and single LVO (SLVO). Methods: The Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2 (RESCUE-Japan Registry 2) enrolled 2,420 consecutive patients with acute LVO who were admitted within 24 h of onset. We compared patient prognosis between MLVO and SLVO in the favorable outcome, defined as a modified Rankin Scale (mRS) score ≤2, and in mortality at 90 days by adjusting for confounders. Additionally, we stratified MLVO patients into tandem occlusion and different territories, according to the occlusion site information and also examined their characteristics. Results: Among the 2,399 patients registered, 124 (5.2%) had MLVO. Although there was no difference between the 2 groups in terms of hypertension as a risk factor, the mean arterial pressure on admission was significantly higher in MLVO (115 vs. 107 mm Hg, p = 0.004). MLVO in different territories was more likely to be cardioembolic (42.1 vs. 10.4%, p = 0.0002), while MLVO in tandem occlusion was more likely to be atherothrombotic (39.5 vs. 81.3%, p < 0.0001). Among MLVO, tandem occlusion had a significantly longer onset-to-door time than different territories (200 vs. 95 min, p = 0.02); accordingly, the tissue plasminogen activator administration was significantly less in tandem occlusion (22.4 vs. 47.9%, p = 0.003). However, interestingly, the endovascular thrombectomy (EVT) was performed significantly more in tandem occlusion (63.2 vs. 41.7%; adjusted odds ratio [aOR], 2.3; 95% confidence interval [CI], 1.1–5.0). The type of MLVO was the only and significant factor associated with EVT performance in multivariate analysis. The favorable outcomes were obtained less in MLVO than in SLVO (28.2 vs. 37.1%; aOR, 0.48; 95% CI, 0.30–0.76). The mortality rate was not significantly different between MLVO and SLVO (8.9 vs. 11.1%, p = 0.42). Discussion/Conclusion: The prognosis of MLVO was significantly worse than that of SLVO. In different territories, we might be able to consider more aggressive EVT interventions.

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Penumbra Consumption Rates Based on Time-to-Maximum Delay and Reperfusion Status: A Post Hoc Analysis of the DEFUSE 3 Trial

Stroke ◽

10.1161/strokeaha.120.033806 ◽

2021 ◽

Author(s):

Shadi Yaghi ◽

Eytan Raz ◽

Seena Dehkharghani ◽

Howard Riina ◽

Ryan McTaggart ◽

...

Keyword(s):

Ischemic Stroke ◽

Infarct Volume ◽

Interquartile Range ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Post Hoc Analysis ◽

Consumption Rates ◽

Post Hoc

Background and Purpose: In patients with acute large vessel occlusion, the natural history of penumbral tissue based on perfusion time-to-maximum (T max ) delay is not well established in relation to late-window endovascular thrombectomy. In this study, we sought to evaluate penumbra consumption rates for T max delays in patients with large vessel occlusion evaluated between 6 and 16 hours from last known normal. Methods: This is a post hoc analysis of the DEFUSE 3 trial (The Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke), which included patients with an acute ischemic stroke due to anterior circulation occlusion within 6 to 16 hours of last known normal. The primary outcome is percentage penumbra consumption, defined as (24-hour magnetic resonance imaging infarct volume–baseline core infarct volume)/(T max 6 or 10 s volume–baseline core volume). We stratified the cohort into 4 categories based on treatment modality and Thrombolysis in Cerebral Infarction (TICI score; untreated, TICI 0-2a, TICI 2b, and TICI3) and calculated penumbral consumption rates in each category. Results: We included 141 patients, among whom 68 were untreated. In the untreated versus TICI 3 patients, a median (interquartile range) of 53.7% (21.2%–87.7%) versus 5.3% (1.1%–14.6%) of penumbral tissue was consumed based on T max >6 s ( P <0.001). In the same comparison for T max >10 s, we saw a difference of 165.4% (interquartile range, 56.1%–479.8%) versus 25.7% (interquartile range, 3.2%–72.1%; P <0.001). Significant differences were not demonstrated between untreated and TICI 0-2a patients for penumbral consumption based on T max >6 s ( P =0.52) or T max >10 s ( P =0.92). Conclusions: Among extended window endovascular thrombectomy patients, T max >10-s mismatch volume may comprise large volumes of salvageable tissue, whereas nearly half the T max >6-s mismatch volume may remain viable in untreated patients at 24 hours.

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Efficient Multimodal MRI Evaluation for Endovascular Thrombectomy of Anterior Circulation Large Vessel Occlusion

Journal of Stroke and Cerebrovascular Diseases ◽

10.1016/j.jstrokecerebrovasdis.2020.105271 ◽

2020 ◽

Vol 29 (12) ◽

pp. 105271

Author(s):

Kunakorn Atchaneeyasakul ◽

David S. Liebeskind ◽

Reza Jahan ◽

Sidney Starkman ◽

Latisha Sharma ◽

...

Keyword(s):

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Endovascular Thrombectomy ◽

Multimodal Mri ◽

Mri Evaluation

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Mobile Interventional Stroke Teams Improve Outcomes in the Early Time Window for Large Vessel Occlusion Stroke

Stroke ◽

10.1161/strokeaha.121.034222 ◽

2021 ◽

Author(s):

Jacob R. Morey ◽

Xiangnan Zhang ◽

Naoum Fares Marayati ◽

Stavros Matsoukas ◽

Emily Fiano ◽

...

Keyword(s):

Scale Score ◽

Time Window ◽

Early Time ◽

National Institutes Of Health ◽

Large Vessel ◽

Late Time ◽

Modified Rankin Scale ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Endovascular Thrombectomy

Background and Purpose: Endovascular thrombectomy for large vessel occlusion stroke is a time-sensitive intervention. The use of a Mobile Interventional Stroke Team (MIST) traveling to Thrombectomy Capable Stroke Centers to perform endovascular thrombectomy has been shown to be significantly faster with improved discharge outcomes, as compared with the drip-and-ship (DS) model. The effect of the MIST model stratified by time of presentation has yet to be studied. We hypothesize that patients who present in the early window (last known well of ≤6 hours) will have better clinical outcomes in the MIST model. Methods: The NYC MIST Trial and a prospectively collected stroke database were assessed for patients undergoing endovascular thrombectomy from January 2017 to February 2020. Patients presenting in early and late time windows were analyzed separately. The primary end point was the proportion with a good outcome (modified Rankin Scale score of 0–2) at 90 days. Secondary end points included discharge National Institutes of Health Stroke Scale and modified Rankin Scale. Results: Among 561 cases, 226 patients fit inclusion criteria and were categorized into MIST and DS cohorts. Exclusion criteria included a baseline modified Rankin Scale score of >2, inpatient status, or fluctuating exams. In the early window, 54% (40/74) had a good 90-day outcome in the MIST model, as compared with 28% (24/86) in the DS model ( P <0.01). In the late window, outcomes were similar (35% versus 41%; P =0.77). The median National Institutes of Health Stroke Scale at discharge was 5.0 and 12.0 in the early window ( P <0.01) and 5.0 and 11.0 in the late window ( P =0.11) in the MIST and DS models, respectively. The early window discharge modified Rankin Scale was significantly better in the MIST model ( P <0.01) and similar in the late window ( P =0.41). Conclusions: The MIST model in the early time window results in better 90-day outcomes compared with the DS model. This may be due to the MIST capturing high-risk fast progressors at an earlier time point. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03048292.

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Outcomes of endovascular thrombectomy with and without bridging thrombolysis for acute large vessel occlusion ischaemic stroke

Internal Medicine Journal ◽

10.1111/imj.14069 ◽

2019 ◽

Vol 49 (3) ◽

pp. 345-351 ◽

Cited By ~ 4

Author(s):

Julian Maingard ◽

Yasmin Shvarts ◽

Ronan Motyer ◽

Vincent Thijs ◽

Paul Brennan ◽

...

Keyword(s):

Ischaemic Stroke ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Endovascular Thrombectomy

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Abstract WP367: Effect of Early Blood Pressure Reduction on Infarct Size in Patients With Large Vessel Occlusion

Stroke ◽

10.1161/str.51.suppl_1.wp367 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

David Baker ◽

Dinesh Jillella ◽

Takashi Shimoyama ◽

Ken Uchino

Keyword(s):

Magnetic Resonance Imaging ◽

Blood Pressure ◽

Infarct Size ◽

Collateral Circulation ◽

Infarct Volume ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Resonance Imaging ◽

Vessel Occlusion ◽

Significant Drop

Introduction: In patients with large vessel occlusion presenting with acute ischemic stroke, cerebral perfusion is a major determinant of stroke severity. However, limited data exists to guide hemodynamic management of these patients early after presentation. In this study, we aim to evaluate the effect of blood pressure reductions during the hyper-acute period on infarct size. Methods: From a clinical stroke registry at a single comprehensive stroke center, we reviewed patients with middle cerebral artery (M1) or internal carotid artery occlusion who underwent hyperacute magnetic resonance imaging (MRI) for endovascular treatment decision in 2018. Infarct volume was determined by area of reduced apparent diffusion coefficient using RAPID software. Collateral circulation was scored based on baseline CT angiogram (good collaterals constituted >50% filling, poor collaterals ≤50% filling). Average mean arterial pressure (MAP) readings from the first hour of presentation were compared to average MAP readings from the hour prior to magnetic resonance imaging. For the purposes of our study, a drop of > 20% in the average MAP was regarded as a significant decrease. We hypothesized that both significant drop in MAP and the presence of good collateral circulation were independent predictors of infarct volume expressed as a logarithmic value in multivariable regression model. Results: Of the 35 patients (mean age 67, mean NIHSS 16) meeting inclusion criteria, 11% of patients experienced an early significant drop in MAP prior to time of MRI. Among patients with a significant drop in MAP, the average decrease was 35 mm Hg ±3.3 among those with significant drop from a baseline mean MAP of 125 mm Hg. In the multivariable analysis adjusting for collateral status, a significant drop in average MAP was independently associated with an increase in infarct volume (β = -0.727, p=0.0306). Collateral status also independently predicted infarct size (β=0.775, p=0.0007). Conclusion: Among ischemic stroke patients with large vessel occlusion, a >20% drop in MAP during the hyper-acute period is associated with larger infarct volumes. Further studies are needed to optimize early blood pressure management in these patients.

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