Intra-arterial Therapy For Acute Ischemic Stroke Research Articles

Abstract 35: MR CLEAN Registry: A Post-trial Multicenter Registry of Intra-arterial Treatment for Acute Ischemic Stroke in the Netherlands

Background & Purpose: Intra-arterial therapy (IAT) is being implemented worldwide as the main treatment option for acute ischemic stroke (AIS). We wondered whether effectiveness and safety results that have been reported in randomized clinical trials can be reproduced in everyday clinical practice. We will report results of the Dutch National post MR CLEAN IAT registry including work flow parameters, primary and secondary outcomes, as well as serious adverse events. Methods: The MR CLEAN Registry is a prospective registry of all patients undergoing IAT for AIS in the Netherlands, started after completion of the MR CLEAN trial in March 2014. Registration was required for reimbursement. A core set was defined, with inclusion criteria similar to those of the MR CLEAN trial, including a proven anterior circulation occlusion and treatment possible withing 6 hours from onset. The primary study outcome is the score on the modified Rankin Scale (mRS) at 90 days. The secondary clinical outcome is NIHSS after 24 to 48 hours. Secondary radiological outcomes include the mTICI score on DSA and final infarct volume and major bleeding on follow up NCCT. We used a propensity weighted and an unadjusted ordinal logistic regression model to compare outcomes in the MR CLEAN Registry core and total dataset with the treatment arm of MR CLEAN. Results: Between March 2014 and August 2016 the inclusion rate of the MR CLEAN Registry has been increasing steadily to an average of 79 (SD 22) per month for a cumulative inclusion of 1548 patients in July 2016 (Figure 1). Conclusions: The MR CLEAN registry data is now being analyzed. Results will be reported at the conference.

Abstract W P10: Lower Intraprocedural Mean Arterial Pressure Predicts Good Outcome and Lower Mortality in Patients Undergoing Endovascular Therapy for Acute Ischemic Stroke

Introduction: Several factors influence the outcome of patients who undergo intra-arterial therapy (IAT) for acute ischemic stroke (AIS). The influence of intra-procedural hemodynamics on functional outcome and mortality has not been studied. There is no data to guide intraprocedural blood pressure (BP) management and it is unknown whether systolic, diastolic, or mean arterial pressure (MAP) is important for determining outcomes. Methods: Retrospective study of patents that underwent IAT for anterior circulation AIS between 1/08- 12/12 was conducted. Detailed intra-procedural hemodynamics, demographics, NIH stroke scale score, IV tPA use, thrombus location, recanalization grade, intracranial hemorrhage were collected. Outcomes measured were in-hospital mortality and 30-day good outcome defined as modified Rankin Scale score of 0-2. Successful recanalization was defined as TICI 2b-3 and ICH was classified into parenchymal hematoma (PH1+2) and hemorrhagic infarction (HI 1+ 2). Results: The cohort in the analysis consisted of 190 patients (56% females, mean age 67 + 15 years). Thirty-six (19%) patients died in-hospital, and 25 (17%) achieved an mRS 0-2. Intra-procedural maximum systolic BP (SBP) and maximum MAP were significantly lower in the good outcome group (Table 1). In multivariable logistic regression analysis, maximum MAP was an independent predictor of good outcomes along with baseline CT ASPECTS score, and successful recanalization. Maximum MAP was also an independent predictor of mortality along with age and presence of PH 1+2 ICH. Conclusions: Maximum intraprocedural MAP was an independent predictor of good outcome and mortality in in patients undergoing IAT for AIS. This results may have implications for intraprocedural BP management.

Poor outcomes of elderly patients undergoing multimodality intra-arterial therapy for acute ischemic stroke

ObjectiveThe incidence of acute ischemic stroke is highest in the elderly. Information regarding outcomes of elderly patients undergoing different modalities of intra-arterial therapy (IAT) for acute ischemic stroke (AIS) is scarce and conflicting. This study compares the safety, technical efficacy and outcomes of elderly patients (≥80 years) to non-elderly patients (<80 years) who underwent multimodality IAT. MethodsFrom a registry of consecutive patients treated with IAT for AIS at our institution over a 3.5-year period, patients with anterior circulation occlusions aged ≥80 years were compared to the patients <80 years. ResultsBetween 2008 and 2012, 24 patients ≥80 years (elderly) and 95 patients <80 years (non-elderly) received IAT for anterior circulation occlusions. In the elderly, there were more females (66.7% vs. 28.4%, p=<0.001) and atrial fibrillation (58.3% vs. 25.2%, p=0.003). Between the 2 groups, there was no difference in NIHSS score (17.2 vs. 16.3, p=0.17), THRIVE score (4.21 vs. 4.39, p=0.633), recanalization rate (70.1% vs. 85.3%, p=0.13), or severe reperfusion hemorrhages (8.3% vs. 4.2%, p=0.425). There was no significant difference in 3-month mortality (33.3% vs. 16.8%, p=0.28); however, fewer elderly patients reached good 3-month outcome (0% vs. 40.0%, p=<0.001). After controlling for baseline factors, only female gender (OR 5.3, 95% CI 1.7–16.7; p=0.04) and higher 3-month mRS (OR 1.6; 95% CI 1.1–2.40; p=0.008) were independently associated with elderly age. ConclusionDespite similar safety profiles and recanalization rates, elderly patients had poor functional outcomes after IAT. Intra-arterial therapy in the elderly should be pursued very cautiously only after careful analysis of the risks and benefits for each patient.

Abstract 205: Optimizing Prediction Scores for Poor Outcome After Intra-arterial Therapy for Anterior Circulation Acute Ischemic Stroke

Background: Intra-arterial therapy (IAT) is an approach to promote recanalization of large artery occlusions (LAO) in acute ischemic stroke (AIS) but is resource intensive. Previous studies evaluated different variables that affect clinical outcome after IAT. To better identify patients who have poor outcomes despite IAT, we compared the performance of previous predictive scoring systems that relied either on clinical or imaging variables in patients undergoing IAT. We then combined imaging and clinical variables to optimize a score that would better predict poor outcome after IAT for AIS. Methods: We studied consecutive AIS patients undergoing IAT at UT-Houston for LAO (MCA or ICA) from 01/03 to 05/11. We collected demographics and clinical variables and analyzed CT head scans using the ASPECTS scores by raters blinded to outcomes. Independent predictors of poor outcome (mRS 4–6) with p values ≤0.1 were evaluated as score variables using sensitivity analysis and logistic regression. Spearman’s correlation and ROC curves were used to evaluate the final score. Houston Intra-arterial Therapy 2 (HIAT2) score ranged from 0–10 with points for: age (≤59=0, 60–79=2, ≥80 years=4), Glucose (&lt;150=0, ≥150=1), NIHSS (≤10=0), 11–20=1, ≥21=2), ASPECTS (8–10=0, ≤ 7=3). The score was created using 75% of the dataset (build group) and tested on the remaining 25% (test group). Previously published prediction scores (HIAT, THRIVE, ASPECTS) were compared against HIAT2. Results: Table 1 shows the clinical features for the 163 patients collected. Fig 1 shows the proportion of poor outcome based on HIAT-2. Patients with HIAT2 ≥ 5 were more likely to have a poor outcome at discharge (OR 6.43, 95% CI 2.75–15.02, p&lt;.001). After adjusting for reperfusion (TICI≥2b, p=.7) and time from symptom onset to recanalization (p=.4), HIAT2 remained a significant independent predictor of poor outcome (OR 5.88, 95% CI 1.96–17.64, p=.02). Fig 2 shows the performance of HIAT2 against THRIVE, HIAT and ASPECTS as well as the validation of HIAT-2. Conclusions: Clinical prediction scores for patients undergoing IAT (HIAT, THRIVE) proved superior to the ASPECTS score. The HIAT2 score, which combines clinical and imaging variables, performed better than all previous scores in predicting the chance of poor outcome after IAT for anterior circulation LAO.

Endovascular Treatment of Acute Ischemic Stroke May Be Safely Performed With No Time Window Limit in Appropriately Selected Patients

The traditional time window for acute ischemic stroke intra-arterial therapy (IAT) is <6 hours, which is based on pharmacological thrombolysis without penumbral imaging. This study was conducted to determine the safety of patient selection for IAT based on perfusion mismatch rather than time. A cohort of consecutive patients treated with IAT was identified by database review. Patients were selected for IAT based on the presence of perfusion mismatch using CT perfusion or MRI regardless of stroke duration. Thrombolytics were minimized after 6 hours in favor of mechanical embolectomy or angioplasty+/-stenting. Outcomes (National Institutes of Health Stroke Scale, modified Rankin Scale) were assessed by independent examiners. A multivariate analysis was performed to compare those treated <6 hours (early) with those treated >6 hours (late). Fifty-five patients (mean National Institutes of Health Stroke Scale=19.7+/-5.7) were treated, 34 early and 21 late, with mean time-to-intervention of 3.4+/-1.6 hours and 18.6+/-16.0 hours, respectively. Thrombolysis In Myocardial Ischemia 2 or 3 recanalization was achieved in 82.8% early and 85.7% late patients (P=1.0). Intracerebral hemorrhage occurred in 25.5% overall, but symptomatic intracerebral hemorrhage occurred in 8.8% of the early and 9.5% of the late patients (P=1.0). Thirty-day mortality was similar (29.4% versus 23.8%, P=0.650). At 3 months, 41.2% and 42.9%, respectively, achieved a modified Rankin Scale <or=2 (P=0.902). Only presenting National Institutes of Health Stroke Scale was a predictor of modified Rankin Scale <or=2 (OR 0.794[95% CI 0.68 to 0.92], P=0.009) and death (adjusted OR 1.29[95% CI 1.04 to 1.59], P=0.019). In appropriately selected patients, IAT for acute ischemic stroke can be performed safely regardless of stroke duration. The concept of an acute ischemic stroke treatment window for IAT should be re-evaluated with a clinical trial selecting patients with perfusion mismatch.