Anterior Circulation Large Vessel Occlusion Stroke Research Articles

Direct endovascular treatment: an alternative for bridging therapy in anterior circulation large-vessel occlusion stroke.

Whether intravenous thrombolysis prior to endovascular treatment in patients with anterior circulation large-vessel occlusion (LVO) is indispensable remains unclear. The aim was to retrospectively compare, in a Chinese population, the effectiveness and safety of direct endovascular treatment (DEVT) initiated within 4.5 h after onset with bridging therapy in acute anterior circulation LVO stroke patients. A total of 363 patients, 160 in the bridging therapy group and 203 in the DEVT group, were enrolled between 2014 and 2016. Using propensity score matching analysis, 276 patients were matched. A modified Rankin Scale score of 0-2 was considered as good functional outcome. Good functional outcome at 90 days in the DEVT group [40.6% (56/138)] did not significantly differ from that in the bridging group [44.9% (62/138)] (P = 0.53). Rates of symptomatic intracranial hemorrhage [13.8% (19/138) vs. 13.0% (18/138), P = 1.00] and mortality [25.4% (35/138) vs. 23.9% (33/138), P = 0.88] within 90 days were also not significantly different. Patients in the DEVT group had a lower rate of asymptomatic intracranial hemorrhage [28.3% (39/138) vs. 44.9% (62/138), P = 0.01] and a higher rate of successful reperfusion [92.0% (127/138) vs. 81.9% (113/138), P = 0.02]. Our results suggest that, in Chinese patients with anterior circulation LVO stroke, direct endovascular mechanical thrombectomy initiated within an intravenous thrombolysis time window carries similar effectiveness to that of bridging therapy and a decreased asymptomatic intracranial hemorrhage risk. DEVT may be an alternative for bridging therapy. Future randomized controlled trials are warranted.

Abstract TP154: Infarct Volume and Prolonged Intubation are Critical Determinants of Inpatient Rehabilitation Cost in Anterior Circulation Large Vessel Occlusion Stroke Patients

Introduction: Anterior circulation large vessel occlusion (ACLVO) stroke is one of the most devastating stroke subtypes. Significant recent advances, including endovascular thrombectomy, have markedly improved ACLVO stroke outcomes. The economic burden of ACLVO stroke treatment is now an important consideration. Our study investigates the critical determinants of acute inpatient rehabilitation (AIR) cost in ACLVO stroke. Methods: We utilized comprehensive patient-level cost-tracking software to calculate AIR costs for ACLVO stroke patients at our institution between July 2012-October 2014. Cost was calculated from the hospital perspective. Patient demographics, clinical course, neurologic exam, and imaging findings were analyzed. Variables with p-value <0.20 in univariate analysis were included in multivariable analysis to determine significant predictors of AIR cost (p<0.05). Results: 65 patients were included in our analysis (median age 61 [IQR 54-73], median AIR admit NIHSS 12 [6-16]). Univariate analysis results are shown (Figure). In our multivariable analysis the only statistically significant predictors of AIR cost were the patient’s final infarct volume (p<0.001) and intubation >48 hours during the hospitalization (p=0.044). AIR costs increased by $66.46 for every 1 cubic centimeter increase in infarct volume. Conclusion: Infarct volume and intubation >48 hours were significant predictors of AIR cost in ACLVO stroke patients at our institution. ACLVO stroke interventions that limit infarct volume may decrease AIR costs, in addition to avoidance of intubation and aggressive pursuit of extubation when feasible.

Abstract 132: Final Infarct Volume is a Critical Determinant of Hospitalization Cost in Anterior Circulation Large Vessel Occlusion Stroke

Background: Anterior circulation large vessel occlusion (ACLVO) stroke, one of the most devastating stroke subtypes, is associated with substantial economic burden. Identifying predictors of increased ACLVO stroke hospitalization cost is essential to developing cost-effective treatment strategies. Methods: We utilized comprehensive patient-level cost-tracking software to calculate hospitalization costs for ACLVO stroke patients at our institution between July 2012-October 2014. Patient demographics and neuroimaging findings were analyzed. Predictors of hospitalization cost were determined using multivariable linear regression. In addition to our primary analysis (all eligible ACLVO patients), we conducted subgroup analyses by treatment (endovascular, IV tPA-only, and no reperfusion therapy) and sensitivity analyses. Results: 341 patients (median age 69 [IQR 57-80], median NIHSS 16 [IQR 13-21], median hospitalization cost $16,446 [IQR $9823-$27,165]) were included in our primary analysis; final infarct volume (FIV), parenchymal hematoma, age, obstructive sleep apnea, and baseline NIHSS were significant predictors of hospitalization cost (Figure). FIV alone accounted for 20.51% of the total variance in hospitalization cost. Notably, FIV was consistently the most robust predictor of increased cost across primary, subgroup, and sensitivity analyses. Over the observed range of FIVs in our cohort, each additional 1cc of infarcted brain tissue increased hospitalization cost by $122.35. Conclusion: FIV is a critical determinant of increased hospitalization cost in ACLVO stroke. Therapies resulting in reduced FIV may not only improve clinical outcomes, but prove cost-effective.

Abstract WMP10: Validation of the Pittsburgh Response to Endovascular Therapy (PRE) Score in IMS3

Background: The Pittsburgh Response to Endovascular therapy (PRE) score incorporates patient’s age, initial NIHSS and pre-treatment CT ASPECTS to predict good outcome in anterior circulation large vessel occlusion (LVO) patients. Further validation of this tool is needed before clinical applicability. Objective: To externally validate the PRE score in a randomized trial cohort of anterior circulation LVO patients. Methods: Patients in IMS3 who had LVO involving the intracranial internal carotid artery (ICA), M1 or M2 middle cerebral artery (MCA) confirmed either by CT or conventional angiography and had a documented pre-randomization CT ASPECTS, baseline NIHSS and 3-month mRS were included. The PRE score was calculated as follows: Age (years)+ 2xNIHSS - 10xASPECTS. The predictive power of the PRE score for good outcome (3-month mRS 0-2) was compared to THRIVE, SPAN and HIAT-2 scores. Rate of achieving mRS 0-2 was compared across previously published PRE score risk categories. Results: 407 patients in IMS3 (Endovascular arm: 319 Control arm: 88) had ICA, M1 or M2 occlusions. The cohort had mean age of 66±12 years, median NIHSS 18 [IQR 14-21], median ASPECTS 8 [IQR 6-9] and 38.2% achieved good outcome (mRS 0-2). Age (p<0.001), NIHSS (p<0.001) and ASPECTS (p<0.001) were independent predictors of good outcome. PRE score had good predictive power for mRS 0-2 (AUC=0.73) and Barthel Index≥95 (AUC=0.71) regardless of the treatment arm (AUC=0.72 in both) or reperfusion status. The predictive power for good outcome was similar to HIAT2 (p=0.9) and THRIVE (p=0.10) and slightly superior to SPAN (p=0.06) (Fig 1A). In the endovascular arm, successful reperfusion predicted good outcome (OR 3.1 p<0.001) independently of the PRE score. Rates of good outcome in PRE score risk groups were comparable to the original PRE score derivation cohort (Fig 1B). Conclusions: Our results confirm the validity of the PRE score as a prognostic tool in anterior circulation LVO stroke patients.

Outcomes after endovascular treatment for anterior circulation stroke presenting as wake-up strokes are not different than those with witnessed onset beyond 8 hours

ObjectivePrevious studies have suggested that patients with wake-up stroke (WUS) may have superior outcomes compared with patients with a witnessed late time of onset after revascularization. We sought to test...

Abstract 2627: Outcomes After Endovascular Treatment For Anterior Circulation Stroke Presenting Beyond 8 Hours Of Time Last Seen Well Do Not Differ In Wake-up Strokes Vs. Witnessed Onset Beyond 8 Hours

Objective: Patients with wake-up stroke are thought to have different outcomes compared to patients with known late time of onset. We thought to verify this hypothesis by determining clinical outcomes, mortality and rate of parenchymal hematoma (PH) in patients with anterior circulation large vessel occlusion stroke (ACLVOS) treated with endovascular therapy at our center. Methods: Retrospective review of a prospectively acquired database from consecutive patients meeting the following criteria: (1) ACLVOS, (2) endovascular treatment initiated beyond 8hrs from time last seen well (TLSW). Treatment selection was based on the presence of a small infarct core/large penumbra assessed through visual inspection on MRI or CTP by the treating physician. In patients undergoing MRI (n=55) pre-procedure infarct volumes on DWI were measured through automated volumetric analysis. Results: We identified 130 patients (mean age 64; mean baseline NIHSS 14, male gender 55%). Patients were divided into three groups. Group 1: patients with wake-up stroke (39%, n=51). Group 2: patients with witnessed onset beyond 8hrs from TLSW (55%, n=72). Group 3: patients without witnessed onset but TLSW>8hrs (5%, n=7). Occlusion locations were as follows: M1-55%, M2-12%, ICA terminus-32% and ICA origin (tandem occlusion)-28%. Successful recanalization (TIMI 2/3) was achieved in 109 patients (84%). The rate of 90 day favorable outcome (modified Rankin score (mRS) ≤ 2) was 55% (n=68/124). PH occurred in 15/130 (12%) patients and the 3 month mortality rate was 18% (n= 22/124). Favorable outcome rates amongst Group 1 (50%, n=24/48), Group 2 (59.5%, n=41/69) and Group 3 (42.9%, n=3/7) were not significantly different (p=0.49, by ANOVA). Mean pre-procedure DWI lesion volume was 18.7 cc in Group 1 vs. 18.3 cc in group 2 (p=0.9). No difference was noted between Group 1, Group 2 and Group3 regarding PH (13.7%, 8.3%, 13.3% respectively, p nonsignificant) or mortality at 3 months (18.7%, 17.4%, 14.3% respectively, p nonsignificant). Multivariate logistic regression model identified only successful recanalization (OR 2.9, p 0.001, CI 1.59-5.44) and age (OR 0.96, p 0.03, CI 0.93-0.99) as predictors of favorable outcome. Conclusion: In patients with ACLVOS presenting beyond 8 hours from TLSW who are selected based on similar imaging characteristics, clinical outcomes following endovascular treatment do not seem to differ according to mode of presentation relative to TLSW.