Circulation Large Vessel Occlusion Stroke Research Articles

Arterial Spin Labelling Patterns in Acute Large Vessel Occlusion Stroke

Background: Arterial spin labelling (ASL) is a noncontrast, magnetic resonance perfusion technique which can provide information about the parenchymal perfusion status and collaterals in acute stroke. Its role in the setting of large vessel occlusion (LVO) is underutilized due to the limited availability of magnetic resonance imaging (MRI) in the emergency settings. However, it might serve as an useful adjunct to other perfusion modalities in future. Objective: To study ASL perfusion patterns in anterior circulation LVO stroke and evaluate the presence of arterial transit artefacts (ATA) as a surrogate marker of collaterals. Methods: We performed a retrospective analysis of our mechanical thrombectomy database over the last 2 years for acute stroke cases in which ASL perfusion as part of MRI was performed. ASL perfusion patterns in acute LVO stroke were reviewed, with respect to presence of ATA and diffusion-weighted imaging (DWI)-ASL mismatch. Inter-rater reliability was analyzed between 2 readers of varying experience. Baseline variables were analyzed between those with and without ATA. Results: Out of 95 patients, 78 had anterior circulation occlusions, among which 27 had ASL. Type I (with ATAs) was seen in 11 patients and all of these had DWI mismatch. Type II (without ATAs) was seen in 16 patients. Of these, 15 had mismatch with DWI and only 1 had no mismatch. Inter-rater reliability for the detection of ATA on ASL was substantial (Cohen’s k—0.64). No statistical significance was noted between ATA and clinical outcomes. Conclusion: ASL patterns vary amongst patients with LVO stroke and can be classified based on the presence of ATA since resulting DWI mismatch actually indicates a pseudo-perfusion deficit.

May 2021 Stroke Highlights

May 2021 <i>Stroke</i> Highlights

Fast and slow progressors of infarct growth in basilar artery occlusion strokes

BackgroundHeterogeneity in the infarct growth rate among anterior circulation large vessel occlusion (LVO) strokes has triage and treatment implications. Such data are lacking for basilar artery occlusion (BAO) strokes. We...

Endovascular reperfusion outcomes in patients with a stroke and low ASPECTS is highly dependent on baseline infarct volumes

BackgroundPatients with large vessel occlusion stroke (LVOS) and a low Alberta Stroke Program Early CT Score (ASPECTS) are often not offered endovascular therapy (ET) as they are thought to have...

Abstract P513: Effect of Premorbid Antiplatelet Medication on Infarct Volume at 24 Hours After Late Window Presentation With Anterior Circulation Large Vessel Occlusion

Introduction: We sought to evaluate the effect of premorbid antiplatelet medication on 24 hour infarct volume in late presenting patients with anterior circulation large vessel occlusion. Methods: This is a secondary analysis of the DEFUSE 3 trial. The primary outcome is infarct volume on a 24-hour MRI scan (volume of DWI positive tissue). The primary predictor is premorbid use of an antiplatelet medication. We fit linear regression models to 24-hour infarct volume and adjusted for admission infarct volume, age, sex, treatment arm, anticoagulant use, time from stroke onset to presentation, hypoperfusion intensity ratio, tPA administration, admission NIH Stroke Scale, glucose, and systolic blood pressure. In a sensitivity analysis, we included recanalization status in the model (no vs. partial vs. complete recanalization). All models had variance inflation factors &lt;2, indicating acceptable multicollinearity. Results: We included 149 patients, of which 51 (34.2%) took premorbid antiplatelet medication. The mean±SD 24-hour infarct volume was 51.7±50.1 in antiplatelet versus 80.4±93.6 ml in control patients (p=0.04). In the adjusted regression model, taking an antiplatelet medication had a beta coefficient of -31.2 (95% CI, -55.0, -7.4; p=0.011). The other significant predictors of 24-hour infarct volume were admission glucose, baseline infarct volume, and HIR. In the sensitivity analysis with recanalization status in the model (n=132), premorbid antiplatelet use remained associated with 24-hour infarct volume (beta=-29.6, 95% CI -55.8, -3.4, p=0.027). Conclusion: For patients with late window anterior circulation large vessel occlusion stroke, premorbid use of an antiplatelet medication was associated with a ~30 mL smaller 24-hour infarct volume on MRI. Possible explanations for this finding include reduced clot burden, improved clot lysis, the anti-inflammatory effects of antiplatelet medications, or the results could be due to chance.

Abstract P505: Prediction of Infarct Volume at the 24 Hours After Late Window Presentation With Perfusion Imaging in Patients With Anterior Circulation Large Vessel Occlusion

Introduction: We sought to evaluate the accuracy of perfusion-weighted imaging (PWI) in late presenting patients for estimating the infarct volume at 24 hours after presentation. Methods: This is a secondary analysis of DEFUSE 3, which included stroke patients with anterior circulation occlusion within 6-16 hours of last known normal. The primary outcome is the final infarct volume on a 24-hour MRI scan (volume of DWI positive tissue), adjusted for the baseline infarct volume. We censored 3 patients with 24-hour follow-up MRI infarct volumes &gt;300 mL, which we considered non-physiologic for a hemispheric stroke. The primary predictors are the baseline volume of Tmax &gt;6s, Tmax &gt;10s, and hypoperfusion intensity ratio (HIR: Tmax10/Tmax6) on CT/MR perfusion at hospital admission. We stratified the cohort into 4 categories (untreated, TICI 0-2a, TICI 2b, and TICI3) and fit linear regression models to each of our predictors. Results: We included 147 patients, of which 69 were untreated, 17 had TICI 0-2a, 46 had TICI 2b, and 15 had TICI 3. In untreated patients, both HIR and Tmax10 volume were predictive of adjusted 24-hour follow-up infarct volume (Table). In treated patients, there were no consistent relationships between the perfusion imaging variables and adjusted final infarct volume (Table). Conclusion: For patients with late window anterior circulation large vessel occlusion stroke, HIR and Tmax10 volume appear to be reliable predictors of subsequent infarct volume in untreated patients. For patients treated with thrombectomy, further research is warranted to better understand the more complex relationship between baseline perfusion imaging and the 24 hour, and beyond, infarct volume.

Abstract MP36: Blood Pressure Reductions in the Hyperacute Phase of Large Vessel Occlusion Ischemic Stroke Are Associated With Infarct Progression and Poor Functional Outcome

Introduction: Decreases in blood pressure (BP) during endovascular therapy (EVT) have been associated with infarct progression and worse outcome after large vessel occlusion (LVO) stroke. However, BP trajectories in the hyperacute phase prior to EVT have not been well characterized. We used high-frequency BP and hemodynamic monitoring to study the timing of BP reductions during the hyperacute period of stroke and evaluated their relation to infarct progression and functional outcome. Methods: We prospectively enrolled patients with anterior circulation LVO stroke undergoing EVT. BP and cardiac hemodynamic variables were recorded every 20 seconds from ER admission until the end of EVT using non-invasive finger plethysmography. Patients underwent initial CT perfusion imaging and a follow-up MRI at 24 hours to calculate infarct growth. The following hemodynamic parameters were defined as exposure variables: the difference between admission MAP and lowest MAP (ΔMAP), MAP drop&gt; 20% from admission, MAP&lt;70 mmHg, and SBP&lt;140 mmHg. Functional outcome was measured with the modified Rankin Scale (mRS) at 90 days. Core associations between BP reductions and outcomes were studied using linear regression and logistic regression models. Results: 45 patients underwent continuous BP monitoring (age 72±17; 58% female; NIHSS 13±6). Aggregated time series data revealed a marked BP reduction around the time of imaging from which patients recovered (mean SBP 33 mmHg, duration 18 min). A sustained decrease in BP was observed after groin puncture without return to baseline BP levels. A linear regression analysis revealed a 13ml infarct growth for every 10 mmHg reduction in ΔMAP (p=0.054). Patients were divided into two groups based on median ΔMAP = 29. Those with ΔMAP ≤29 had better functional outcome at 90 days (34.78% vs. 9.09%, p = 0.038). Conclusion: Marked and frequently iatrogenic BP reductions occur around the time of initial imaging and may present a potential target for therapeutic intervention. Decrease in blood pressure before reperfusion may increase the risk of infarct progression and poor functional outcome. Changes in cardiac hemodynamic variables throughout the acute stroke period suggest a potential role for fluid resuscitation for hemodynamic optimization.

Abstract P514: Clinically Approximated Hypoperfused Tissue in Large Vessel Occlusion Stroke

Introduction: Patient selection for thrombectomy of acute ischemic stroke (AIS) caused by large vessel occlusion (LVO) in the delayed time window (&gt;6 hours) is dependent on delineation of clinical-core mismatch or radiological target mismatch using perfusion imaging. Selection paradigms not involving advanced imaging and software processing may reduce time to treatment and broaden eligibility. We aim to develop a conversion factor to approximately determine the volume of hypoperfused tissue using the NIHSS score [CAT volume (clinically approximated tissue)] and explore its ability to identify patients eligible for thrombectomy in the late time window. Methods: We performed a retrospective analysis of anterior circulation LVO strokes at three comprehensive stroke centers. Demographic, clinical (NIHSS score, TLKW-time last known well) and imaging [computed tomography with perfusion (CTP) processed using RAPID, IschemaView] information was analyzed. A conversion factor, which is a multiple of the NIHSS score (one multiple for NIHSS score &lt;10 and another for NIHSS score ≥10), was derived to calculate CAT volumes. Accuracy (sensitivity and specificity) of CAT-based thrombectomy eligibility criteria (similar to DEFUSE-3 criteria but using CAT volume instead of Tmax &gt;6 seconds volume) was tested using DEFUSE-3 criteria eligibility as a gold standard. Result: Of the 309 LVO strokes [mean age of 70 ±14, 46% male, median NIHSS 16 (12-20)] included in this study, 38% of patients arrived beyond 6 hours of TLKW. Conversion factors derived (derivation cohort-center A:187) based on median (50 th percentile) values of Tmax &gt;6s volume for NIHSS &lt;10 subgroup was 15 and for NIHSS ≥10 subgroup was 6. Subsequently calculated CAT volume-based eligibility criteria yielded a sensitivity of 100% and specificity of 92% in detecting DEFUSE-3 eligible patients (AUC-0.92 CI-0.82-1) in the validation cohort (center B and C:122). Conclusions: Clinical severity of stroke (NIHSS score) may be used to calculate the volume of hypoperfused tissue during LVO stroke. Clinically approximated hypoperfused tissue (CAT) volumes for NIHSS score &lt;10 (using a factor of 15) and ≥10 (using a factor of 6) subgroups can accurately identify DEFUSE-3 eligible patients.

Angiographic early hyperemia in the middle cerebral artery territory after thrombectomy is associated with favorable clinical outcome in anterior circulation stroke.

Angiographic cortical early hyperemia (EH) is frequently observed after endovascular thrombectomy (EVT) for large vessel occlusion (LVO) stroke. The aim of the study is to investigate the relationship between EH and clinical outcomes. Between January 2015 and September 2018, consecutive patients who underwent EVT for anterior circulation LVO stroke with optimal recanalization (modified thrombolysis in cerebral infarction 2b or 3) were included. Angiographic studies after immediate reperfusion were used for analysis for cortical EH sign. Clinical functional outcomes were evaluated with the modified Rankin Scale (mRS) at 90 days. Safety outcomes, including mortality and intracerebral hemorrhage, were assessed. The association of EH between clinical functional and safety outcomes was analyzed. A total of 143 patients were analyzed (mean age: 71 years; median National Institutes of Health Stroke Scale score: 18). A positive EH sign was observed in 88 (62%) patients. Good functional outcome at 90 days was significantly different between the EH+ and EH- groups (p = .0157). Intracerebral hemorrhage and mortality did not differ between groups. In multivariate logistic regression analysis, EH was an independent predictor for good clinical outcome (mRS ≤ 2, odds ratio: 3.49, p = .0034) in addition to young age. Results revealed that the presence of EH is associated with better clinical outcome at 90 days, but not associated with increased hemorrhagic complication. These findings with clinically relevant implications require further validation. • Angiographic cortical hyperemia is a common finding immediately after endovascular thrombectomy. • Presence of cortical hyperemia is an independent prognostic factor for good clinical outcome. • Hemorrhagic complication is not associated with cortical hyperemia.

Acute and Chronic Kidney Dysfunction and Outcome After Stroke Thrombectomy

Data on the impact of kidney dysfunction on outcome in patients with stroke due to large vessel occlusion are scarce. The few available studies are limited by only considering single kidney parameters measured at one time point. We thus investigated the influence of both chronic kidney disease (CKD) and acute kidney injury (AKI) on outcome after mechanical thrombectomy. We included consecutive patients with anterior circulation large vessel occlusion stroke receiving mechanical thrombectomy at our center over an 8-year period. We extracted clinical data from a prospective registry and investigated kidney serum parameters at admission, the following day and throughout hospital stay. CKD and AKI were defined according to established nephrological criteria. Unfavorable outcome was defined as scores of 3–6 on the modified Rankin Scale 3 months post-stroke. Among 465 patients, 31.8% had an impaired estimated glomerular filtration rate (eGFR) at admission (< 60 ml/min/1.73 m2). Impaired admission eGFR was related to unfavorable outcome in univariable analysis (p = 0.003), but not after multivariable adjustment (p = 0.96). Patients frequently met AKI criteria at admission (24.5%), which was associated with unfavorable outcome in a multivariable model (OR 3.03, 95% CI 1.73–5.30, p < 0.001). Moreover, patients who developed AKI during hospital stay also had a worse outcome (p = 0.002 in multivariable analysis). While CKD was not associated with 3-month outcome, we identified AKI either at admission or throughout the hospital stay as an independent predictor of unfavorable prognosis in this study cohort. This finding warrants further investigation of kidney–brain crosstalk in the setting of acute stroke.

Blood pressure variability and outcomes after mechanical thrombectomy based on the recanalization and collateral status.

Background:Blood pressure (BP), recanalization status, and collateral circulation are important factors for cerebral autoregulation after stroke. We aimed to investigate the association of various BP variability (BPV) parameters with clinical outcomes after mechanical thrombectomy (MT) according to recanalization and collateral status.Methods:We included 502 consecutive patients who underwent MT due to anterior circulation large vessel occlusion stroke at three comprehensive stroke centers. BPV parameters were standard deviation (SD), maximum/minimum BP, coefficient of variation (CV) and successive variation (SV). The clinical outcomes included 90-day functional outcome assessed by modified Rankin Scale score and symptomatic intracranial hemorrhage (sICH).Results:Among the included patients, 219 (43.6%) achieved good functional outcomes and 59 (11.8%) developed sICH. After adjusting for confounders, higher systolic BP (SBP) variability [CV (odds ratio (OR), 1.089, p = 0.035), SV (OR, 1.082, p = 0.004). and SD (OR, 1.074, p = 0.027)] was associated with a lower likelihood of a favorable outcome. In addition, higher SBP [CV (OR, 1.156, p = 0.001) and SD (OR, 1.118, p = 0.001)] were significantly associated with increased odds of sICH. Moreover, the relationship between BPV and the outcomes depended on recanalization status. However, regardless of collateral status, a higher BPV after MT was associated with worse outcomes.Conclusions:Higher SBP SD and CV during the first 24 h after MT was a powerful predictor of worse clinical outcomes, regardless of the collateral status. However, the effects of BPV on outcomes were more substantial among patients with successful reperfusion.

Non-invasive markers of liver fibrosis and outcome in large vessel occlusion stroke

Background:Liver fibrosis has been identified as an outcome predictor in cardiovascular disease and has been associated with hematoma expansion and mortality in patients with primary intracerebral hemorrhage. We aimed to explore whether clinically inapparent liver fibrosis is related to neurological outcome, mortality, and intracranial hemorrhage risk in ischemic stroke patients after mechanical thrombectomy.Methods:We included consecutive patients with anterior circulation large vessel occlusion stroke treated at our center with mechanical thrombectomy between January 2011 and April 2019. Clinical data had been collected prospectively; laboratory data were extracted from our electronic hospital information system. We calculated the Fibrosis-4 index (FIB-4), an established non-invasive liver fibrosis test. The main outcomes were postinterventional intracranial hemorrhage, unfavorable functional status (modified Rankin scale scores of 3–6), and mortality three months post-stroke.Results:In the 460 patients (mean age 69 years, 49.3% female) analyzed, FIB-4 indicated advanced liver fibrosis in 22.6%. Positive FIB-4 was associated with unfavorable neurological outcomes and mortality three months post-stroke, even after correction for co-factors [Odds Ratio (OR) 2.15 for unfavorable outcome in patients with positive FIB-4, 95% confidence interval (CI) 1.21–3.83, p = 0.009, and 2.16 for mortality, 95% CI 1.16–4.03, p = 0.01]. However, FIB-4 was neither related to hemorrhagic transformation nor symptomatic intracranial hemorrhage. Moreover, atrial fibrillation was more frequent in patients with liver fibrosis (p < 0.001). Two further commonly-used liver fibrosis indices (Forns index and the Easy Liver Fibrosis Test) yielded comparable results regarding outcome and atrial fibrillation.Conclusions:Clinically inapparent liver fibrosis (based on simple clinical and laboratory parameters) represents an independent risk factor for unfavorable outcomes, including mortality, at three months after stroke thrombectomy. Elevated liver fibrosis indices warrant further hepatological work-up and thorough screening for atrial fibrillation in stroke patients.

White Matter Acute Infarct Volume After Thrombectomy for Anterior Circulation Large Vessel Occlusion Stroke is Associated with Long Term Outcomes

ObjectivesDespite the proven efficacy of endovascular thrombectomy (EVT) for large vessel occlusion stroke, over half treated remain functionally disabled or die. Infarct topography may have implications for prognostication, patient selection, and the development of tissue-specific neuroprotective agents. We sought to quantify white matter injury in anterior circulation acute infarcts post-EVT to understand its significance and identify its determinants. Materials and MethodsDemographics, history, presentations, and outcomes for consecutive patients treated with EVT were recorded in a prospectively maintained database at a single center. Acute infarct masks were coregistered to standard space. Standard atlases of white matter, cortex, and basal ganglia were used to determine region-specific infarct volumes. Results167 individuals were identified with median age 69 years and 53% women. 85% achieved adequate reperfusion (TICI 2b-3) after EVT; 43% achieved 90-day functional independence (mRS 0-2). Median infarct volumes were 45cc (IQR 18-122) for total, 17cc (6-49) for white matter, 21cc (4-53) for cortex, and 5cc (1-8) for basal ganglia. The odds of 90-day mRS 0-2 were reduced in patients with larger white matter infarct volume (cc, OR=0.89, 95%CI=0.81-0.96), independent of cortex infarct volume, basal ganglia infarct volume, age, NIHSS, and TICI 2b-3 reperfusion. Reperfusion-to-MRI time was associated with white matter infarct volume (hr, β=0.119, p=0.017), but not cortical or basal ganglia infarct volume. ConclusionsThese data quantitatively describe region-specific infarct volumes after EVT and suggest the clinical relevance of white matter infarct volume as a predictor of long-term outcomes. Further study is warranted to examine delayed white matter infarction and the significance of specific white matter tracts.

A Nomogram Model to Predict Malignant Cerebral Edema in Ischemic Stroke Patients Treated with Endovascular Thrombectomy: An Observational Study.

PurposeMalignant cerebral edema (MCE) in patients undergoing endovascular thrombectomy (EVT) is not uncommon and can reduce the benefit of EVT. We aimed to develop a nomogram model to predict the risk of MCE in ischemic stroke patients after EVT.Patients and MethodsWe retrospectively collected patients treated with EVT caused by anterior circulation large vessel occlusion stroke at two comprehensive stroke centers. MCE was defined as midline shift >5 mm at the septum pellucidum or pineal gland with obliteration of the basal cisterns or the need for early decompressive hemicraniectomy. A multivariate logistic model was utilized to construct the best-fit nomogram model. The discrimination and calibration of the nomogram were estimated using the area under the receiver operating characteristic curve (AUC-ROC) and Hosmer–Lemeshow test.ResultsA total of 370 patients (mean age, 67.2±11.9 years; male, 56.8%) were enrolled in the final analysis. Among them, 71 (19.2%) patients experienced MCE after EVT treatment. After adjustment for potential confounders, age, baseline National Institutes of Health Stroke Scale score, collateral circulation, fast blood glucose level and recanalization were independent predictors of MCE and were incorporated into the nomogram. The AUC-ROC value of the nomogram was 0.805 (95% confidence interval [CI]: 0.750–0.860). The Hosmer–Lemeshow goodness-of-fit test showed good calibration of the nomogram (P = 0.681).ConclusionThe nomogram composed of age, baseline National Institutes of Health Stroke Scale score, blood glucose level, collateral circulation and recanalization may predict the probability of MCE in anterior circulation large vessel occlusion stroke patients treated with EVT.

Local Anesthesia Without Sedation During Thrombectomy for Anterior Circulation Stroke Is Associated With Worse Outcome.

The best anesthetic management for mechanical thrombectomy of large vessel occlusion strokes is still uncertain and could impact the quality of reperfusion and clinical outcome. We aimed to compare the efficacy and safety outcomes between local anesthesia (LA) and conscious sedation in a large cohort of acute ischemic stroke patients with anterior circulation large vessel occlusion strokes treated with mechanical thrombectomy in current, everyday clinical practice. Patients undergoing mechanical thrombectomy for anterior large vessel occlusion strokes at 4 comprehensive stroke centers in France between January 1, 2018, and December 31, 2018, were pooled from the ongoing prospective multicenter observational Endovascular Treatment in Ischemic Stroke Registry in France. Intention-to-treat and per-protocol analyses were used. Among the included 1034 patients, 762 were included in the conscious sedation group and 272 were included in the LA group. In the propensity score matched cohort, the rate of favorable outcome (90-day modified Rankin Scale score 0-2) was significantly lower in the LA group than in the conscious sedation group (40.0% versus 52.0%, matched relative risk=0.76 [95% CI, 0.60-0.97]), as well as the rate of successful reperfusion (modified Thrombolysis in Cerebral Infarction grade 2b-3; 76.6% versus 87.1%; matched relative risk=0.88 [95% CI, 0.79-0.98]). There was no difference in procedure time between the 2 groups. In the inverse probability of treatment weighting-propensity score-adjusted cohort, similar significant differences were found for favorable outcomes and successful reperfusion. In inverse probability of treatment weighting-propensity score-adjusted cohort, a higher rate of 90-day mortality and a lower parenchymal hematoma were observed after LA. The sensitivity analysis restricted to our per-protocol sample provided similar results in the matched- and inverse probability of treatment weighting-propensity cohorts. In the Endovascular Treatment in Ischemic Stroke registry mainly included patients in early time window (<6 hours), LA was associated with lower odds of favorable outcome, successful reperfusion, and higher odds of mortality compared with conscious sedation for mechanical thrombectomy of large vessel occlusion.

Sex-Related Differences after Endovascular Treatment of Acute Ischemic Stroke in the ‘Real World’

BackgroundGender differences are often reported in the field of ischemic stroke, although most of such discrepancies were observed in randomized trials involving highly selected populations. We therefore explored gender differences regarding 90-day outcomes in large vessel occlusion (LVO) strokes receiving endovascular treatment in a real world setting. MethodsThis prospective registry included anterior and/or posterior circulation LVO strokes admitted between January 2014 and December 2019 who received mechanical thrombectomy up to 24 hours from symptoms onset or last known to be well. We explored sex-related differences in rates of functional independence (modified Rankin Scale, mRS, ≤2) at 90 days. Secondary outcomes included “National Institutes of Health Stroke Scale” (NIHSS) at 24 hours, successful reperfusion defined as modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b/3, death, and symptomatic intracranial hemorrhage (sICH). ResultsA total of 288 LVO stroke patients comprised the study population, involving 148 (51.4%) women. Females were older (71.4±15.7 vs. 66.1±14.0 years, p=0.003) and had lower rates of coronary artery disease (15% vs. 24%, p=0.05). The median time from symptoms onset to hospital arrival was 315 min (IQR 139.5-495.0) in females and 255.0 (IQR 117.0-405.0) in males (p=0.052). Rates of mRS ≤2 at 90 days were comparable (females 46% vs. males 49%, p=0.50). Successful reperfusion was achieved in 82% of females and 89% of males (p=0.10). Rates of sICH (females 10% vs. males 13%, p=0.47) and death (females 18% vs. males 21%, p=0.50) at 90 days were similar. NIHSS at 24 hours was the strongest predictor of functional independence at 90 days (area under ROC curve 0.92 (95%CI 0.87; 0.95)]. ConclusionsOur prospective registry involving a real world setting suggests that females are equally likely to achieve good outcomes after endovascular treatment despite being older and having delayed hospital arrival compared to males. In addition, we found that NIHSS at 24 hours was the strongest predictor of functional independence at 90 days, sICH, and death.

Early Brain Imaging Shows Increased Severity of Acute Ischemic Strokes With Large Vessel Occlusion in COVID-19 Patients.

Background and Purpose:Reports are emerging regarding the association of acute ischemic strokes with large vessel occlusion and coronavirus disease 2019 (COVID-19). While a higher severity of these patients could be expected from the addition of both respiratory and neurological injury, COVID-19 patients with strokes can present with mild or none respiratory symptoms. We aimed to compare anterior circulation large vessel occlusion strokes severity between patients with and without COVID-19.Methods:We performed a comparative cohort study between patients with COVID-19 who had anterior circulation large vessel occlusion and early brain imaging within 3 hours from onset, in our institution during the 6 first weeks of the COVID-19 outbreak and a control group admitted during the same calendar period in 2019.Results:Twelve COVID-19 patients with anterior circulation large vessel occlusion and early brain imaging were included during the study period and compared with 34 control patients with anterior circulation large vessel occlusion and early brain imaging in 2019. Patients in the COVID-19 group were younger (P=0.032) and had a history of diabetes mellitus more frequently (P=0.039). Patients did not significantly differ on initial National Institutes of Health Stroke Scale nor time from onset to imaging (P=0.18 and P=0.6, respectively). Patients with COVID-19 had more severe strokes than patients without COVID-19, with a significantly lower clot burden score (median: 6.5 versus 8, P=0.016), higher rate of multivessel occlusion (50% versus 8.8%, P=0.005), lower DWI-ASPECTS (Diffusion-Weighted Imaging–Alberta Stroke Program Early Computed Tomography Scores; median: 5 versus 8, P=0.006), and higher infarct core volume (median: 58 versus 6 mL, P=0.004). Successful recanalization rate was similar in both groups (P=0.767). In-hospital mortality was higher in the COVID-19 patients’ group (41.7% versus 11.8%, P=0.025).Conclusions:Early brain imaging showed higher severity large vessel occlusion strokes in patients with COVID-19. Given the massive number of infected patients, concerns should be raised about the coming neurovascular impact of the pandemic worldwide.

Hyperdense vessel sign as a potential guide for the choice of stent retriever versus contact aspiration as first-line thrombectomy strategy

BackgroundThe first-pass effect (FPE) has emerged as a key metric for efficacy in mechanical thrombectomy (MT). The hyperdense vessel sign (HDVS) on non-contrast head CT (NCCT) indicates a higher clot...

Anterior circulation large vessel occlusion stroke in Saudi Arabia: Prevalence, predictors, and outcome

ObjectiveAnterior circulation Large Vessel Occlusion (LVO) stroke comes with significant morbidity and mortality. With the advent of endovascular interventions, its management has revolutionized. For health authorities to build systems and allocate resources, its burden, predictors, and outcome must be determined. MethodsIn a single tertiary care center, we retrospectively collected data from 1495 ischemic stroke patients to determine anterior circulation LVO prevalence, predictors, and outcome. Patients must have radiologically proven ischemic stroke within 24 hours before arrival at the emergency department. Anterior circulation LVO related stroke was defined as evidence of new anterior circulation infarct detected on neuroimaging, and vascular imaging confirming anterior circulation Large Vessel Occlusion. Data on demographics, vascular risk factors, treatment with reperfusion therapy, modified Rankin Scale (mRS) at admission, National Institute of Health Stroke Scale (NIHSS) at admission, length of stay (LOS) in days, and in-hospital comorbidities and death were collected. Regression analysis was done to determine the predictors and outcomes of anterior circulation LVO ischemic strokes. ResultsWe found anterior circulation LVO in 27.8% (95 % CI 25.5–30.0) of all ischemic stroke patients. Atrial fibrillation and admission National Institute of Health Stroke Scale (NIHSS) were the strongest predictors of LVO [OR 2.33, P = 0.0011 and OR 1.17, P < 0.0001] respectively. Occurrence of LVO was associated with worse disability score (mRS ≥ 3) [47.22 vs. 19.81% (P = 0.0073)], longer hospitalization in days [Median 9.0 vs. 3.0, IQR (14.0 vs. 5.0) P = 0.0432)], and was more likely to results in patient admission to intensive care unit [Mean 17.59 vs. 3.70 % (P = 0.0002)]. ConclusionStroke with large vessel occlusion in Saudi Arabia is not uncommon. Its burden and outcome deserve national attention, as effective treatment is now readily available.

Clinical Characteristics of Fast and Slow Progressors of Infarct Growth in Anterior Circulation Large Vessel Occlusion Stroke (5388)

Clinical Characteristics of Fast and Slow Progressors of Infarct Growth in Anterior Circulation Large Vessel Occlusion Stroke (5388)