The significance of the RACE (Rapid Arterial Occlusion Evaluation) scale in acute ischemic stroke

Background and purpose: The intracranial blood flow at the site of arterial occlusion in acute ischemic stroke can be measured with Transracial Doppler (TCD) using the Thrombolysis in Brain Ischemia (TIBI) grading system. The TIBI ranges from 0 to 5, where 0 no flow and 5 normal flow. Our study’s aim is to modify the TIBI grading system in order to make it simple to implement in an acute stroke setting. METHODS: We classified Modified TIBI grading as: Grade 0- no flow, Grade 1- Bad flow: there is systolic flow but no diastolic flow or systolic flow with delayed acceleration and diastolic flow, Grade 2-Good flow: normal upstroke systolic flow and diastolic flow with decreased mean flow velocity compared to contralateral vessel by 30 %. We used the clotbust database to evaluate the modified TIBI scoring system. Poor long-term outcome was defined as modified rankin scale (MRS) score > 2. RESULTS: Total of 369 patients with acute ischemic stroke and intracranial arterial occlusion received IV r TPA. Median age was 71 years (IQ range: 58.7-79), Sex: women: 170(46.1%). Median NIHSS was 16 (IQ range: 12.7-2), 17/98 (17.3%) patients with modified TIBI 0, 73/205(35.6%) with modified TIBI 1 and 31/66( 47%) with modified TIBI 2 had achieved complete recanalization ( p value=0001). The multiple logistic regression model revealed Baseline higher NIHSS, systolic BP, glucose and modified TIBI grade 0 were independent negative predictor of complete recanalization. Patients with modified TIBI 3 had high probability of complete recanalization compared to TIBI 0(OR 3.14, CI 95%: 1.4-6.8, P=0.004).Poor outcome at 3 months (MRS>2) was found in 46/75(61.3%) patients with modified TIBI 0, 94/170(55.3%) with modified TIBI 1 and 19/38(33.3%) with modified TIBI 2(P value <0.004). On logistic model age, baseline NIHSS, glucose and TIBI 0 were independent negative predictors of good outcome.Although statistically insignificant but patients with modified TIBI 3 had a trend towards high probability of good functional outcome (OR: 1.73, CI 95%:0.73-4.12, p=0.20). CONCLUSION: Modified TIBI grading system is simplified version of TIBI grading and is easy to understand and apply clinically. It also predicts reliably the recanalization and functional outcome.

Download Full-text

Abstract 74: Early Arterial Recanalization After Intra-venous Tissue-Plasminogen-Activator Treatment in the Interventional Management of Stroke-3 Study

Stroke ◽

10.1161/str.45.suppl_1.74 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Ruediger Von Kummer ◽

Andrew M Demchuk ◽

Lydia D Foster ◽

Bernard Yan ◽

Wouter J Schonewille ◽

...

Keyword(s):

Ischemic Stroke ◽

Clinical Outcome ◽

Acute Ischemic Stroke ◽

Internal Carotid ◽

Arterial Occlusion ◽

Posterior Circulation ◽

Stroke Patients ◽

Vessel Occlusion ◽

Tissue Plasminogen ◽

Arterial Recanalization

Background: Data on arterial recanalization after IV t-PA treatment are rare. IMS-3 allows the study of variables affecting arterial recanalization after IV t-PA in acute ischemic stroke patients with CTA-proved major artery occlusions. Methods: Of 656 acute ischemic stroke patients in IMS-3, 306 were examined with baseline CTA and randomized either to IV t-PA (N=95) or to IV t-PA followed by digital subtraction angiography (DSA) and endovascular therapy (EVT) (N=211). Comparison of baseline CTA to DSA within 5 hours of stroke onset assessed early arterial recanalization after IV t-PA. A central core lab categorized DSA vessel occlusion as “no, partial, or complete”. We studied the association between arterial occlusion sites on baseline CTA with early recanalization for the endovascular group and analyzed its impact on clinical outcome at 90 days. Results: In the EVT group, 22 patients (10.4%) had no CTA intracranial occlusions, but 1 extracranial occlusion; 42 patients (19.9%) had occlusions of intracranial internal carotid artery (ic-ICA); 10 patients (4.7%) had tandem occlusions of the cervical ICA and middle cerebral artery (MCA); 95 patients (45.0%) had MCA-trunk (M1) occlusions, 33 patients (15.6%) had M2 occlusions, 3 patients (1.4%) had M3/4 occlusions, and 6 patients (2.8%) occlusions within posterior circulation. Partial or complete recanalization occurred in 28.6% of patients before DSA and was marginally associated with occlusion site (p=0.0525) (8 patients (19.0%) with ic-ICA occlusion, 0 patients with tandem ICA/MCA occlusions, 34 patients (35.8%) with M1 occlusions, 11 patients (33.3%) with M2 occlusions, 0 patients with M3/4 occlusions, and 1 patient (16.7%) with occlusion within posterior circulation). Three CTA negative patients had intracranial occlusions on DSA. Thirty-two patients (59.3%) with early recanalization achieved mRS of 0-2 at 90 days compared to 51 patients (38.4%) without early recanalization (p=0.0099). There was no relationship between early recanalization and time to IV t-PA or mean t-PA dose. Conclusion: Before EVT, IV rt-PA may facilitate arterial recanalization and better clinical outcome in about one third of patients.

Download Full-text

Abstract TMP89: Collaterals and Reperfusion Mediate Blood Pressure Changes in Acute Ischemic Stroke

Stroke ◽

10.1161/str.48.suppl_1.tmp89 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

David S Liebeskind ◽

Graham W Woolf ◽

Nerses Sanossian ◽

Jason D Hinman ◽

Radoslav Raychev ◽

...

Keyword(s):

Blood Pressure ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Arterial Occlusion ◽

Patient Specific ◽

Pressure Data ◽

Blood Pressure Data ◽

Pressure Changes ◽

Continuous Blood Pressure

Background: The pathophysiology and optimal management of blood pressure changes in acute ischemic stroke remain unknown. Blood pressure guidelines do not consider patient-specific or serial data on dynamic blood pressure readings. We investigated continuous blood pressure data during endovascular therapy for acute stroke to discern changes associated with collaterals, recanalization and reperfusion. Methods: Continuous monitoring blood pressure data was collected in consecutive cases of endovascular therapy for acute ischemic stroke due to ICA or proximal MCA occlusion. Angiography details were independently analyzed to document site of arterial occlusion, baseline collateral grade, time of device deployments, time of recanalization, time of final reperfusion, final AOL recanalization and final TICI reperfusion. Statistical analyses correlated instantaneous and serial blood pressure changes with these angiographic parameters. Results: 80 patients (median age 73 years; 33 women) were studied. Arterial lesions included 37 ICA and 41 proximal M1 MCA occlusions. Collateral grade prior to intervention included 2 ASITN grade 4, 26 grade 3, 23 grade 2, 6 grade 1 and 0 grade 0. oTICI2C reperfusion scores after thrombectomy included 2 TICI 3 (100%), 22 TICI 2C (90-99%), 25 TICI o2B (67-89%), 9 TICI m2B (50-66%), 19 TICI 2A (<50%) and 3 TICI 0/1. More robust collateral grade was associated with greater reperfusion scores (r=0.32, p=0.028). The change in blood pressure (ΔBP) from earliest BP to time of recanalization was mean 59% of ΔBP during the entire procedure. Better collaterals were associated with lower BP prior to recanalization (r=-0.377, p=0.012). Lower BP prior to recanalization was linked with greater TICI reperfusion (r=-0.242, p=0.050). Higher TICI reperfusion scores were also associated with a greater drop or ΔBP at the time of recanalization (r=0.269, p=0.031). AOL recanalization was not related to ΔBP. Conclusions: Collaterals and reperfusion, but not recanalization, mediate blood pressure changes in acute ischemic stroke. Prospective, precision medicine stroke studies should leverage patient-specific, real-time data on continuous blood pressure with imaging correlates to define BP goals of future in-hospital management.

Download Full-text

Bright Vessel Appearance on Arterial Spin Labeling MRI for Localizing Arterial Occlusion in Acute Ischemic Stroke

Stroke ◽

10.1161/strokeaha.114.007797 ◽

2015 ◽

Vol 46 (2) ◽

pp. 564-567 ◽

Cited By ~ 29

Author(s):

Roh-Eul Yoo ◽

Tae Jin Yun ◽

Jung Hyo Rhim ◽

Byung-Woo Yoon ◽

Koung Mi Kang ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Arterial Spin Labeling ◽

Arterial Occlusion ◽

Spin Labeling

Download Full-text

Comparison of Treatment Methods in the Management of Acute Ischemic Stroke.

International Journal Of Medical Science And Clinical Invention ◽

10.18535/ijmsci/v7i11.03 ◽

2020 ◽

Vol 7 (11) ◽

pp. 5073-5079

Author(s):

Ertugrul Altınbilek ◽

Abdullah Algın ◽

Mustafa Çalık ◽

Ece Guven ◽

Derya Ozturk ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Arterial Occlusion ◽

Intravenous Thrombolysis ◽

Mortality Rates ◽

Treatment Modalities ◽

Complication Rates ◽

Tissue Destruction ◽

Duration Of Treatment ◽

Nihss Score

Aim: Acute ischemic stroke is an emergency clinical condition that occurs as a result of acute intracranial arterial occlusion and neural tissue destruction. In this study, we aimed to evaluate the treatment outcomes in patients who were performed intravenous thrombolysis (IVT), mechanical thrombectomy (MT), or both. Materials and Methods: In this retrospective study, 131 patients who underwent IVT, MT or both who has the diagnosis of AIS in our hospital between June 1, 2018, and February 1, 2018, were assessed. Age, sex, concomitant chronic diseases, NIHSS score, treatment-related complications, the time between disease presentation and hospital arrival, the duration of treatment, the one-month mortality rates and modified Rankin scores (MRS) were recorded. One-month mortality, NIHSS, and MRS were compared with treatment modalities and other factors. Results: The mean age of 131 patients included in the study was 71.79±12.67. The MRS did not differ significantly in the groups with IVT, MT, and IVT+MT (p> 0.05). In the IVT and MT groups, the NIHSS score increased significantly after the treatment (p <0.05). In the MT+IVT group, the NIHSS score after treatment did not change significantly (p> 0.05). Conclusion: No significant relationship between mortality rates and MRS with treatment method was found. Complication rates were also not different among three treatment groups.

Download Full-text

Preprocedure change in arterial occlusion in acute ischemic stroke patients undergoing endovascular treatment by computed tomographic angiography

The American Journal of Emergency Medicine ◽

10.1016/j.ajem.2015.01.054 ◽

2015 ◽

Vol 33 (5) ◽

pp. 631-634 ◽

Cited By ~ 5

Author(s):

Adnan I. Qureshi ◽

Mushtaq H. Qureshi ◽

Farhan Siddiq ◽

Daraspreet Kainth ◽

Ameer E. Hassan ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Arterial Occlusion ◽

Computed Tomographic Angiography ◽

Stroke Patients ◽

Computed Tomographic ◽

Tomographic Angiography

Download Full-text

Abstract T MP7: Single Center Experience With A Direct Aspiration Technique (adapt) For Endovascular Treatment Of Acute Ischemic Stroke

Stroke ◽

10.1161/str.46.suppl_1.tmp7 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

RAPHAEL BLANC ◽

Hocine Redjem ◽

Bruno bartolini ◽

Gabriele Ciccio ◽

Thomas Robert ◽

...

Keyword(s):

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Functional Outcomes ◽

Arterial Occlusion ◽

Single Center ◽

Single Center Experience ◽

Tandem Occlusion ◽

Aspiration Technique ◽

Procedural Complications

Background: We report our single center experience of endovascular treatment of stroke by the technique of direct clot aspiration. Methods: From September 2013 to July 2014, from our prospectively gathered database, we reviewed 114 patients presenting with large vessels occlusion in the settings of acute ischemic stroke and treated with the ADAPT technique in first intention. Results: Hundred and fourteen patients (55 female and 54 male patients (mean age: 64 y.o) presented with a median NIHSS score of 15,9 (1-26). The localisation of arterial occlusion was the MCA in 52/114 (45%), the ICA in 16/114 (14%), a tandem occlusion in 35/114 (30,7%) and the vertebro basilar territory in 11/114 (9,65%). Procedures were performed under sedation in 66% of cases and general anesthesia in 33%. The aspiration technique alone was successful in achieving TICI 2b/3 in 48,2% of cases (55/114) with a mean of 2 passes. The additional use of stent retrievers improved the TICI 2b/3 revascularization rate to 87,5%. With aspiration alone, the average time from groin puncture to at least TICI 2b recanalization was 37 min (from clot contact to recanalisation: 17 min). Ninety day functional outcomes was available for 87/114 patients with 50% of good functional outcomes (mRS≤ 0-2) and 15% death (mRS 6). For the overal series there were 10 cases (8,7%) of procedural complications (one non occlusive dissection, 4 distal emboli, and 5 Subarachnoid hemorrhages) and 2 symptomatic intracerebral hemorrhages (2,5%). Discussion: The aspiration technique utilizing large bore aspiration catheters technique alone was effective in 48% of the cases being fast, safe and simple, but to achieve a recanalization rate of 87,5% it add to be completed by the use of stentrievers in the other cases. The relevance of this technique needs to studied in larger prospective multicentric studies.

Download Full-text

Abstract 1911: Recanalization of Proximal Arterial Occlusion in the SENTIS Trial

Stroke ◽

10.1161/str.43.suppl_1.a1911 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

David S Liebeskind ◽

Ashfaq Shuaib ◽

Martin Köhrmann ◽

William P Dillon ◽

Songling Liu ◽

...

Keyword(s):

Logistic Regression ◽

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Medical History ◽

Controlled Trial ◽

Arterial Occlusion ◽

Stroke Severity ◽

Nihss Score ◽

Logistic Regression Models ◽

Multivariable Logistic Regression

Background: Collateral circulation may enhance recanalization in acute ischemic stroke. Augmentation of collaterals with partial aortic occlusion may promote recanalization and thereby influence outcomes in the SENTIS randomized controlled trial of the NeuroFlo device. We conducted a post hoc analysis of angiography acquired in SENTIS to evaluate potential differences in recanalization rates between NeuroFlo-treated and non-treated arms, accounting for site of arterial occlusion. Methods: Blinded imaging expert review of baseline and 6-hour follow-up angiography (CTA, MRA, or DSA) from the core lab was conducted for evaluation of recanalization. Recanalization was defined as TIMI 2-3 in the arterial segment distal to baseline occlusion. Baseline demographics, stroke presentation characteristics, and medical history variables were analyzed with respect to recanalization in univariate and subsequent multivariable logistic regression models after adjusting by treatment arm. Results: Serial angiography was available in 109/515 SENTIS subjects, including 56 in the treatment arm and 53 in the non-treated arm. Baseline demographics, stroke presentation characteristics, and medical history variables did not differ statistically between arms. Across all sites of arterial occlusion, recanalization occurred in 25.7% of cases, with similar rates between device (25.0%) and medical therapy (26.4%) arms. Age and baseline stroke severity (NIHSS score) were significant predictors of recanalization in univariate analyses. Multivariable logistic regression analyses confirmed that baseline NIHSS score was the sole predictor of recanalization (OR 0.90, p=0.0458) per one unit increase, with decreased recanalization in more severe strokes. Device treatment was not associated with significant increases in recanalization rates (p=NS). Recanalization of terminal internal carotid artery (12.5%), proximal MCA or M1 (17.9%) and M2 (46.7%) occlusions was not different between arms (all p=NS). Recanalization of proximal arterial occlusion in acute ischemic stroke cases enrolled in SENTIS was more frequent in M2 occlusions. Conclusions: More severe strokes at baseline were less likely to recanalize and device therapy did not increase recanalization rates. Treatment with the NeuroFlo device may invoke mechanisms of collateral perfusion distinct from direct arterial recanalization.

Download Full-text

Abstract TP23: Feasibility Of The Combination Of The Restore ™ Thrombectomy Device And The Reflex ™ Access And Aspiration Catheter For The Treatment Of Acute Ischemic Stroke

Stroke ◽

10.1161/str.44.suppl_1.atp23 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Peter Schramm ◽

Ramona Schramm ◽

Michael Knauth

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Arterial Occlusion ◽

Distal Segment ◽

Vessel Occlusion ◽

Intracranial Vessel ◽

Flow Restoration ◽

Thrombectomy Device ◽

Clot Aspiration ◽

New Treatment

Introduction: Larger distal access catheter systems for treatment of acute intracranial vessel occlusion enable both clot aspiration and introduction of flow restoration devices. We present the first clinical data of a large lumen hyperflexible intracranial distal aspiration catheter (ReFlex™ 5F, 058” ID x 125cm, Covidien, Irvine, CA) combined with the ReStore™ Thrombectomy microcatheter (Reverse Medical, Irvine, CA) for endovascular treatment of acute ischemic stroke. Patients and Methods: The ReStore™ consists of a flexible, tapered microcatheter with a braided mesh retrieval element attached to its distal segment. The retrieval element is deployed through the advancement of a guidewire or the ReAct™ stylet through the lumen to radially expand the retrieval element. Infusion of rt-PA within the thrombus is possible through small side holes of the ReStore™. Nine patients (62 y - 88 y, 5f/4m) with acute occlusion of the MCA were treated with the combination of ReStore™ and the ReFlex™ aspiration catheter within 6 hours after symptom onset. Median NIHSS score upon arrival was 16 (range 8 - 18). TICI flow in the target vessel segment was assessed prior and after recanalization procedure. Results: Thrombectomy with the combination of ReStore™ and ReFlex™ was performed as initial mechanical treatment in 8 cases. In one case, prior treatment with other stentriever systems failed, whereas the combination of ReStore™ and ReFlex™ lead to TICI 3. TICI 2b or 3 was achieved in 7 patients (77.8%); in 2 patients, TICI 2a was achieved. Immediate flow restoration while activating ReStore™ was accomplished in all 9 cases. Mean time from first angiopgraphy to first perfusion was 39.1 min (range 9-88 min). In 4 cases, additional rt-PA (10 mg) was administered directly into the thrombus through the ReStore™. In 2 cases, subsequent implantation of a permanent intracranial stent was performed. The mean number of ReStore™ activations to achieve final TICI score was 2.2 ± 1.1. One patient experienced periprocedural subarachnoid hemorrhage as a severe adverse event. Conclusion: The combination of ReStore™ and the ReFlex™ aspiration catheter is a promising new treatment option for both flow restoration and aspiration in patients suffering from acute intracranial arterial occlusion.

Download Full-text

Capability of stroke scales to detect large vessel occlusion in acute ischemic stroke : A pilot study

Ideggyógyászati Szemle ◽

10.18071/isz.74.0099 ◽

2021 ◽

Vol 74 (3-4) ◽

pp. 99-103

Author(s):

Gábor Tárkányi ◽

Zsófia Nozomi Karádi ◽

Péter Csécsei ◽

Edit Bosnyák ◽

Gergely Fehér ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Area Under The Curve ◽

Arterial Occlusion ◽

Large Vessel ◽

Screening Methods ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Cross Sectional ◽

Stroke Centre

Rapid changes of stroke management in recent years facilitate the need for accurate and easy-to-use screening methods for early detection of large vessel occlusion (LVO) in acute ischemic stroke (AIS). Our aim was to evaluate the ability of various stroke scales to discriminate an LVO in AIS. We have performed a cross-sectional, observational study based on a registry of consecutive patients with first ever AIS admitted up to 4.5 hours after symptom onset to a comprehensive stroke centre. The diagnostic capability of 14 stroke scales were investigated using receiver operating characteristic (ROC) analysis. Area under the curve (AUC) values of NIHSS, modified NIHSS, shortened NIHSS-EMS, sNIHSS-8, sNIHSS-5 and Rapid Arterial Occlusion Evaluation (RACE) scales were among the highest (>0.800 respectively). A total of 6 scales had cut-off values providing at least 80% specificity and 50% sensitivity, and 5 scales had cut-off values with at least 70% specificity and 75% sensitivity. Certain stroke scales may be suitable for discriminating an LVO in AIS. The NIHSS and modified NIHSS are primarily suitable for use in hospital settings. However, sNIHSS-EMS, sNIHSS-8, sNIHSS-5, RACE and 3-Item Stroke Scale (3I-SS) are easier to perform and interpret, hence their use may be more advantageous in the prehospital setting. Prospective (prehospital) validation of these scales could be the scope of future studies.

Download Full-text