Acute Anterior Large Vessel Occlusion Research Articles

Abstract 082: Comparing Efficacy and Safety of First‐Line Thrombectomy Strategies for Acute Anterior Large Vessel Occlusion Strokes

Abstract 082: Comparing Efficacy and Safety of First‐Line Thrombectomy Strategies for Acute Anterior Large Vessel Occlusion Strokes

The benefit of favorable venous outflow profile is mediated through reduced microvascular dysfunction in acute ischemic stroke.

Venous outflow (VO) is emerging as a marker of microvascular integrity in acute ischemic stroke. Using hemorrhagic transformation (HT) and infarct growth as mediators, we tested whether a favorable VO profile benefited functional outcome by reducing consequences of microvascular dysfunction. Patients receiving thrombectomy in three comprehensive stroke centers due to acute anterior circulation occlusion were included. VO was assessed semi-quantitatively by the opacification of ipsilateral vein of Labbé, Trolard and superficial middle cerebral vein. HT was graded on follow-up CT. Infarct growth volume (IGV) was the difference of final infarct volume and baseline core volume. The association of VO and functional independence (90-day modified Rankin Scale ⩽ 2) was examined by logistic regression. Mediation analysis was performed among VO, HT or IGV, and functional outcome in patients with or without recanalization, respectively. In 242 patients analyzed, VO was strongly correlated with functional independence and VO ⩾ 4 was defined favorable. In 175 patients recanalized, favorable VO was associated with a reduced risk of HT (OR = 0.82, 95% CI 0.71-0.95, p = 0.008), which accounted for 13.1% of the association between VO and favorable outcome. In 67 patients without recanalization, favorable VO was associated with decreased IGV (β = -0.07, 95% CI -0.11 to -0.02, p = 0.007). The association of favorable VO and functional independence was no longer significant (aOR = 4.84, 95% CI 0.87-38.87, p = 0.089) after including IGV in the model, suggesting a complete mediation. In patients with acute anterior large vessel occlusion, the clinical benefit of VO may be mediated through reduced microvascular dysfunction.

Large mismatch profile predicts rapidly progressing brain edema in acute anterior circulation large vessel occlusion patients undergoing endovascular thrombectomy.

Brain edema is a severe complication in patients with large vessel occlusion (LVO) that can reduce the effectiveness of endovascular therapy (EVT). This study aimed to investigate the association of the perfusion profile at baseline computed tomography (CT) perfusion with rapidly progressing brain edema (RPBE) after EVT in patients with acute anterior LVO. We retrospectively reviewed consecutive data collected from 149 patients with anterior LVO who underwent EVT at our center. Brain edema was measured by the swelling score (0-6 score), and RPBE was defined as the swelling score increased by more than 2 scores within 24 h after EVT. We investigated the effect of RPBE on poor outcomes [National Institute of Health Stroke Scale (NIHSS) score and modified Rankin scale (mRS) score at discharge, the occurrence of hemorrhagic transformation, and mortality rate in the hospital] using the Mann-Whitney U-test and chi-square test. A multivariate logistic regression model was used to assess the relationship between perfusion imaging parameters and RPBE occurrence. Overall, 39 patients (26.2%) experienced RPBE after EVT. At discharge, RPBE was associated with higher NIHSS scores (Z = 3.52, 95% CI 2.0-12.0, P < 0.001) and higher mRS scores (Z = 3.67, 95% CI 0.0-1.0, P < 0.001) including the more frequent occurrence of hemorrhagic transformation (χ2 = 22.17, 95% CI 0.29-0.59, P < 0.001) and higher mortality rates in hospital (χ2 = 9.54, 95% CI 0.06-0.36, P = 0.002). Univariate analysis showed that intravenous thrombolysis, baseline ischemic core volume, and baseline mismatch ratio correlated with RPBE (all P < 0.05). After dividing the mismatch ratio into quartiles and performing a chi-square test between quartiles, we found that the occurrence of RPBE in Q4 (mismatch ratio > 11.3) was significantly lower than that in Q1 (mismatch ratio ≤ 3.0) (P < 0.05). The result of multivariate logistic regression analysis showed that compared with baseline mismatch ratio <5.1, baseline mismatch ratio between 5.1 and 11.3 (OR:3.85, 95% CI 1.06-14.29, P = 0.040), and mismatch ratio >11.3 (OR:5.26, 95% CI 1.28-20.00, P = 0.021) were independent protective factors for RPBE. In patients with anterior circulation LVO stroke undergoing successful EVT, a large mismatch ratio at baseline is a protective factor for RPBE, which is associated with poor outcomes.

Factors relating to good outcomes after mechanical thrombectomy for acute anterior circulation ischemic stroke within 4.5 Hours from the onset

Mechanical thrombectomy (MT) has been accepted as a standard treatment worldwide for patients suffering from acute anterior large vessel occlusion (AC-LVO) who can start early MT within 6 hours. However, in Vietnam, there remains a paucity of information regarding factors that can affect outcomes following this treatment. This study aimed to assess the clinical, imaging, and procedural factors related to good outcomes after MT for patients with AC-LVO within 4.5 hours. We analyzed data from 120 patients at Bach Mai hospital who had acute ischemic stroke (AIS) due to AC-LVO and were treated with MT with and without intravenous thrombolysis (IVT) within 4.5 hours from December 2020 to September 2022. Logistic regression analysis was used to examine the associations of clinical, imaging, and procedural variables with a good outcome. Overall, successful revascularization was achieved in 102/120 cases (85.0%) and 70 patients (58.3%) had a good outcome at 90 days. Successful revascularization (OR, 1.40; 95% CI, 1.24-1.58; p&lt;0.01), initial blood glucose level (OR, 0.86; 95% CI, 0.85-0.87; p=0.046), and hemorrhagic transformation (OR, 0.83; 95% CI, 0.76-0.90; p=0.02) were independent factors associated with good outcome at 90 days.

Delayed filling of the superficial middle cerebral vein in acute large artery occlusion.

ObjectiveThis study aimed to determine whether baseline delayed filling of the superficial middle cerebral vein (SMCV) was an independent cause of stroke prognosis in patients with acute anterior large vessel occlusion (LVO).MethodsConsecutive patients with acute LVO [middle cerebral artery M1 ± intracranial internal carotid artery (ICA)] between March 2019 and May 2020 were included. Delayed SMCV was defined as delayed filling of SMCV in the affected side compared with the normal side throughout the venous phase on four-dimensional computed tomographic angiography (4D-CTA) reconstructed from CT perfusion imaging. The modified Rankin scale (mRS) was used to evaluate the prognosis of these patients 3 months after stroke.ResultsOf 54 patients in total, 47 (87.0%) patients presented with baseline delayed SMCV, and 36 (76.6%) patients achieved SMCV reversal (ipsilateral delayed SMCV reversed to bilateral symmetrical SMCV) after reperfusion therapy. Successful reperfusion was independently associated with SMCV reversal [odds ratio (OR) = 69.328, 95% confidence interval (CI) = 2.818–175.342]. A significant association between baseline SMCV delay and a 3-month poor outcome (OR = 19.623, 95% CI = 1.567–245.727, p = 0.021) was observed using a multivariable regression analysis. Compared with patients with persistent delayed SMCV, patients with reversed SMCV did not show a significant difference in the risk of a 3-month poor outcome (OR = 1.177, 95% CI = 0.147–9.448).ConclusionsIn patients with acute LVO, baseline delayed SMCV was an independent cause of poor stroke prognosis, and SMCV reversal cannot reverse the 3-month stroke prognosis. Therefore, the evaluation of baseline SMCV filling status should be strengthened in clinical practice.

Plasma tRNA derivatives concentrations for detecting early brain damage in patients with acute large vessel occlusion and predicting clinical outcomes after endovascular thrombectomy

ObjectiveTransfer RNA (tRNA) is involved in the acute stress response, which results in conformational changes and subsequent fragmentation. Using an antibody against tRNA-specific modified nucleoside 1-methyladenosine, we can selectively detect blood tRNA derivatives from damaged tissues, including neuronal tissue, which serves as a potential marker of early tissue damage. This preliminary study aimed to investigate the correlation between tRNA derivatives and clinical outcomes in patients with acute anterior large vessel occlusion, especially those who underwent endovascular thrombectomy (EVT). MethodsPatients with acute ischemic stroke due to anterior circulation large vessel occlusion were prospectively enrolled in this study. Plasma tRNA derivatives were measured using an enzyme-linked immunosorbent assay with an anti-modified nucleoside 1-methyladenosine antibody. ResultsSeventeen patients were included. The plasma tRNA derivatives concentrations on admission increased significantly, corresponding to the infarction size (r = 0.492, p = 0.038), and were associated with clinical outcomes (p = 0.00309). A good clinical outcome (90-day modified Rankin scale score: 0–2) was achieved in seven patients (41.2%), and all had undergone EVT. Among these patients, tRNA derivatives concentrations were the only preoperative predictor, which was associated with good outcomes (modified Rankin scale score: 0–2) and was significantly lower than those with poor outcomes (modified Rankin scale score: 3–6) (p = 0.0333). Receiver operating characteristic analysis revealed that a tRNA derivative value of ≤ 142.0 mg/mL was associated with good clinical outcomes, with a sensitivity of 85.7% and a specificity of 100% (area under the curve, 0.952; 95% confidence interval: 0.82–1). ConclusiontRNA derivatives concentration may be a sensitive marker of early brain damage in patients with acute large vessel occlusion. Patients with low levels of tRNA derivatives on arrival are likely to benefit from thrombectomy and have the potential to achieve good clinical outcomes.

Predictors of Futile Recanalization After Endovascular Treatment in Patients with Acute Ischemic Stroke in a Multicenter Registry Study

BackgroundFutile recanalization, defined as the early recanalization of an occluded artery failing to improve neurological outcome, remains a persistent concern in the endovascular treatment of acute ischemic stroke. We investigated the occurrence and predictors of futile recanalization after endovascular treatment in a nationwide multicenter stroke registry study. MethodsThe subjects consisted of eligible patients from the Acute Ischemic Stroke Cooperation Group of Endovascular Treatment registry study (2015–2017). Subjects with acute anterior large vessel occlusion who achieved successful angiographic recanalization (defined as modified Thrombolysis in Cerebral Infarction grades 2b or 3) by endovascular treatment were dichotomized into the futile-recanalization group (with a modified Rankin Scale score of 3–6) and the favorable-recanalization group (with a modified Rankin Scale score of 0–2) according to 90-day functional independence. Logistic regression analysis was performed to investigate predictors of futile recanalization. ResultsFutile recanalization was observed in 200 (49.6%) out of 403 patients. On multivariate analysis, older age (>74 vs. ≤74; odds ratio (OR), 2.41; 95% confidence interval (CI), 1.31–4.44; P=0.005), high baseline National Institutes of Health Stroke Scale score (>21 vs. ≤13; OR, 2.52; 95% CI, 1.21–5.28; P=0.014), delayed puncture to recanalization time (>80 vs. ≤80 min; OR, 2.75; 95% CI, 1.67–4.51; P=0.000), and the use of general anesthesia (OR, 1.90; 95% CI, 1.15–3.14; P=0.012) were positively associated with futile recanalization after mechanical thrombectomy. ConclusionsThe incidence of futile recanalization is common following endovascular treatment among Asian patients with anterior circulation occlusion. Advanced age, higher baseline National Institutes of Health Stroke Scale score, delayed puncture to reperfusion, and the use of general anesthesia are associated with lower functional independence 90 days post-treatment despite successful recanalization.

Abstract TP90: Computed Tomography Perfusion Mismatch is Stable Over Time From Onset After Stroke Due to Underestimation of Core Infarct in Late Time Window

Background: Automated computed tomography perfusion (CTP) imaging is proven effective at selecting patients with acute large vessel occlusion (LVO) for endovascular intervention in the extended time window (&gt;6 hours after last known normal [LKN]). However, there are limited data on the likelihood of identifying core infarct-penumbral mismatch in the late time window. Hypothesis: Automated CTP mismatch ratios (Time-to-maximum residue function [T max ] &gt;6s: relative cerebral blood flow [rCBF] &lt;30%) using RAPID software will decrease as time from LKN increases. Methods: We reviewed a retrospective registry of consecutive patients with LVO who underwent CTP within 24h of LKN at 3 academic hospitals between 06/2017 - 12/2017. Unenhanced CT and CTP parameters were compared between patients who presented within 12h of LKN versus 12-24h of LKN. Results: Among 60 included patients, the median age was 78 years (IQR 64-84), 36 (60.0%) were female, and 39 (65.0%) underwent thrombectomy. Patients who presented at 12-24h had poorer ASPECTS scores than patients who presented &lt;12h from LKN (median score 7 [IQR 5-8] vs. 8 [IQR 6-9], p=0.092), but the mismatch ratios were not significantly different (median 5.95 [IQR 2.64-9.11] vs. 3.28 [IQR 2.19-7.70], p=0.509). Longer delay from LKN were associated with a lower ASPECTS score (adjusted β -0.12 points/hr, 95%CI -0.21 - -0.04, p=0.006), which was driven by patients with witnessed symptom onset (adjusted p=0.009; Figure), but no significant change in rCBF &lt;30% (adjusted p=0.360) irrespective of whether symptom onset was witnessed (adjusted p=0.847; Figure). Conclusions: As time progresses in acute anterior LVO, the unenhanced CT may be more sensitive than rCBF&lt;30% for detecting the volume of irreversibly damaged tissue. Figure caption: ASPECTS and rCBF &lt;30% over time. Blue dots indicate patients with witnessed onset (with fitted dashed line), red circles indicate patients with unwitnessed onset (with fitted solid line).

Complete Recanalization May Exert the Most Important Effect on Outcomes of Endovascular Treatment in Acute Ischemic Stroke with Small Infarct Core Beyond 6 Hours

To explore the differences among grades of recanalization on outcomes of endovascular treatment for acute anterior large vessel occlusion with small infarct core beyond the 6-hour time window. Patients beyond the 6-hour time window with Alberta Stroke Program Early Computed Tomography Score >7 were retrospectively enrolled from the endovascular treatment for acute anterior circulation ischemic stroke (ACTUAL) registry. They were divided into 3 groups according to the degree of recanalization: modified treatment in cerebral infarction (mTICI) 0-2a, 2b, and 3. We compared the differences of outcomes among groups on modified Rankin Scale score at 90 days, symptomatic intracerebral hemorrhage within 72 hours, and mortality. A total of 101 patients were enrolled. Median time from onset to groin puncture was 415 minutes (interquartile range: 387-497 minutes). Favorable functional outcomes were significantly better in patients with successful recanalization than in patients with failed recanalization (mTICI 0-2a, 22.7% [5/22]; mTICI 2b, 48.0% [12/25]; and mTICI 3, 61.1% [33/54]; trend P= 0.01). Complete recanalization (mTICI 3) (odds ratio, 5.34; 95% confidence interval, 1.71-16.66; P= 0.004) was associated with good functional outcome. Mortality was different among groups at 90 days (mTICI 0-2a, 36.4% [8/22]; mTICI 2b, 0, [0/25]; P= 0.001; mTICI 0-2a, 36.4% [8/22]; mTICI 3, 9.3% [5/54]; P= 0.008; and mTICI 2b, 0, [0/25]; mTICI 3, 9.3% [5/54]; P= 0.173). There were no significant differences of symptomatic intracranial hemorrhage among groups (mTICI 0-2a, 22.7% [5/22]; mTICI 2b, 12.0% [3/25]; and mTICI 3, 9.3% [5/54]; P= 0.28). For acute anterior circulation stroke patients, who were beyond the 6-hour time window, yet with small ischemic core, complete recanalization following endovascular treatment may play the most important role on clinical outcome.