Large Vessel Occlusion Stroke Patients Research Articles

A dynamic nomogram for predict individual risk of malignant brain edema after endovascular thrombectomy in acute ischemic stroke

The aim of this study was to develop a dynamic nomogram combining clinical and imaging data to predict malignant brain edema (MBE) after endovascular thrombectomy (EVT) in patients with large vessel occlusion stroke (LVOS). We analyzed the data of LVOS patients receiving EVT at our center from October 2018 to February 2023, and divided a 7:3 ratio into the training cohort and internal validation cohort, and we also prospectively collected patients from another stroke center for external validation. MBE was defined as a midline shift or pineal gland shift > 5 mm, as determined by computed tomography (CT) scans obtained within 7 days after EVT. A nomogram was constructed using logistic regression analysis, and its receiver operating characteristic curve (ROC) and calibration were assessed in three cohorts. A total of 432 patients were enrolled in this study, with 247 in the training cohort, 100 in the internal validation cohort, and 85 in the external validation cohort. MBE occurred in 24% (59) in the training cohort, 16% (16) in the internal validation cohort and 14% (12) in the external validation cohort. After adjusting for various confounding factors, we constructed a nomogram including the clot burden score (CBS), baseline neutrophil count, core infarct volume on CTP before EVT, collateral index, and the number of retrieval attempts. The AUCs of the training cohorts were 0.891 (95% CI 0.840–0.942), the Hosmer–Lemeshow test showed good calibration of the nomogram (P = 0.879). And our nomogram performed well in both internal and external validation data. Our nomogram demonstrates promising potential in identifying patients at elevated risk of MBE following EVT for LVOS.

Quantitative Assessment of Reperfusion Impact on Cerebral Edema and Functional Outcomes in Large-vessel Occlusion Stroke Patients (S23.003)

Quantitative Assessment of Reperfusion Impact on Cerebral Edema and Functional Outcomes in Large-vessel Occlusion Stroke Patients (S23.003)

Abstract WP22: “Chopperlysis:” Improved Functional Outcomes Associated With Helicopter Transport in Large Vessel Occlusion Stroke Patients Treated With Tenecteplase

Introduction: Tenecteplase (TNK) is increasingly being utilized for IV thrombolysis in acute ischemic stroke, including for patients with large vessel occlusion (LVO) prior to transfer to an endovascular thrombectomy (EVT) capable center (TCC). However, there is limited data regarding factors that influence functional outcome between the time of TNK administration and TCC arrival. The purpose of this analysis is to characterize the effect of the arrival method on the effectiveness of TNK to improve patient outcomes. Methods: A retrospective registry of stroke patients between 2019-2023 at a single comprehensive stroke center was queried. Patients with LVO stroke who had complete data for method of arrival (i.e. ground transportation versus helicopter), TNK treatment, and available 90-day modified Rankin score (mRS) were included. The primary outcome was a favorable 90-day mRS of 0-2. Categorical variables were reported as frequencies, and associations across variables were analyzed using Chi-square test or Fisher's exact test. Odds ratios were calculated with univariate logistic regressions. Results: Of 2675 patients meeting inclusion criteria, 14.4% arrived by helicopter and 85.6% arrived by ground transportation. 174 (6.5%) were treated with TNK, including 5.1% of ground transported patients and 14.1% of air transported patients. Irrespective of EVT, patients arriving by ground did not differ in likelihood of achieving the primary outcome whether they did or did not receive TNK (53.9% TNK vs. 48.4% no TNK, p=0.35). However, patients arriving by helicopter had a significantly higher likelihood of achieving the primary outcome with TNK, regardless of EVT (60% TNK vs. 41.2% no TNK, p=0.04), and in patients transported by helicopter who did not undergo EVT, there was an even higher likelihood of good functional outcome associated with TNK treatment (69.2% TNK vs. 40.1% no TNK, p=0.049). Conclusion: In our cohort, treatment with TNK was associated with improved functional outcomes in helicopter transported patients but not in those transported by ground, and this benefit was found to be even more robust in patients who did not undergo EVT. Future studies are needed to validate these findings and investigate the underlying pathophysiological mechanism.

Abstract TP149: Pretreatment Parameters Predicting Excellent Recanalization of Large Vessel Occlusion in Patients With Acute Ischemic Stroke

Introduction: In large vessel occlusion (LVO) ischemic stroke patients, better functional outcomes are associated with achieving modified thrombolysis in cerebral infarction (mTICI) score 2C/3 in comparison to 2B. The purpose of this study was to identify pretreatment and interventional predictors of mTICI 2C/3 over 2B reperfusion in patients with LVOs treated successfully with thrombectomy. Methods: Data from two comprehensive stroke centers between 2019-2023 were retrospectively reviewed for LVO acute ischemic stroke patients treated successfully (mTICI 2B/2C/3) with thrombectomy. Primary outcome measure was achieving mTICI 2C/3 (i.e., excellent) revascularization. Demographic variables, CT perfusion parameters, and intervention-related parameters were evaluated as univariate regressors of primary outcome. Significant univariate predictors were included in a forward stepwise multivariate logistic regression, and adjusted odds ratios (aOR) were reported. Results: Of 149 patients, the median age was 70 years old (IQR: 65-78.5), and 57.7% were female. Multivariate logistic regression analyses (AUC = 0.79, 95% CI: 0.68-0.86, p<0.001) showed that patients had a higher likelihood of excellent recanalization with lower admission NIHSS (aOR 0.93, p = 0.036), no history of diabetes mellitus (DM) (aOR 0.42, p = 0.050), no prior stroke (aOR 0.27, p = 0.007), cerebral blood volume (CBV) index >= 0.7 (aOR 3.75, p = 0.007), and thrombectomy with aspiration alone (aOR 2.89, p = 0.012). Conclusions: Robust collateral status (as represented by CBV index), absence of diabetes mellitus, no prior stroke history, lower initial stroke severity, and aspiration thrombectomy were associated with increased likelihood of excellent recanalization amongst technically successfully revascularized LVO stroke patients. Preventative comorbidity management, collateral status on imaging, and thrombectomy technique may optimize chances for excellent recanalization.

Abstract 51: Impact of Cerebral Autoregulation on the Relationship Between Blood Pressure Variability and Functional Outcome Following Endovascular Thrombectomy

Background: Both increased blood pressure (BP) variability and impaired autoregulation have been linked to worse outcome after endovascular thrombectomy (EVT). This study examined the combined effect of these variables on the risk of poor outcome in patients with large-vessel occlusion (LVO) stroke. Methods: Autoregulation was continuously measured for up to 24 hours after EVT and quantified as a moving correlation coefficient between arterial BP and the near-infrared spectroscopy-derived cerebral oxygen saturation. Systolic BP variability was assessed using the standard deviation of the mean. Values were averaged for the entire recording period and dichotomized at the lowest tertile for both variables. Functional outcome was assessed using the modified Rankin scale (mRS) at 90 days and dichotomized into good (mRS 0-2) and poor outcome (mRS 3-6). Results: We included 195 patients (mean age 70 + 16, 45% female, mean NIHSS 14, mean monitoring time 15 + 7 hours). After adjusting for age, NIHSS, ASPECTS, and TICI score, patients with low BP variability and intact autoregulation were significantly more likely to achieve a good outcome than those with high BP variability and impaired autoregulation (OR 3.7, 95% CI 1.2-12.1, p=0.028, Figure 1A). We found an interaction between BP variability and autoregulation (p=0.067). Patients with high BP variability showed a gradual decrease in the probability of a good outcome with worsening autoregulation. However, for patients with low BPV, autoregulation had minimal impact. (Figure 1B). No significant correlation was seen between autoregulatory function and BP variability (r=0.07, p=0.33). Conclusions: For LVO stroke patients with high BP variability after EVT, worse 90-day functional outcome may be exacerbated by impaired autoregulation. These results suggest that autoregulatory status should be considered in the management of BP after EVT to identify high-risk patients and develop individualized treatment strategies.

Outcome of patients with multivessel occlusion stroke after endovascular treatment

Introduction: Little is known about the implications of multivessel occlusions (MVO) in large vessel occlusion stroke patients who undergo endovascular treatment (EVT). Patients and methods: We report data from the MR CLEAN Registry: a prospective, observational study on all stroke patients who underwent EVT in the Netherlands (March 2014–November 2017). We included patients with an intracranial target occlusion in the anterior circulation. An MVO was defined as an MCA occlusion (M1/M2) or intracranial ICA/ICA-T occlusion, with a concurrent second occlusion in the ACA or PCA territory confirmed on baseline CTA. To compare outcomes, we performed a 10:1 propensity score matching analysis with a logistic regression model including potential confounders. Outcome measures included 90-day functional outcome (modified Rankin Scale, mRS) and mortality. Results: Of 2946 included patients, 71 patients (2.4%) had an MVO (87% concurrent ACA occlusion, 10% PCA occlusion, 3% ⩾3 occlusions). These patients were matched to 71 non-MVO patients. Before matching, MVO patients had a higher baseline NIHSS (median 18 vs 16, p = 0.001) and worse collateral status (absent collaterals: 17% vs 6%, p < 0.001) compared to non-MVO patients. After matching, MVO patients had worse functional outcome at 90 days (median mRS 5 vs 3, cOR 0.39; 95%CI 0.25–0.62). Mortality was higher in MVO patients (46% vs 27%, OR 2.11, 95%CI 1.24–3.57). Discussion and conclusion: MVOs on baseline imaging were uncommon in LVO stroke patients undergoing EVT, but were associated with poor functional outcome.

Effect of Cerebral Small Vessel Disease Burden on Infarct Growth Rate and Stroke Outcomes in Large Vessel Occlusion Stroke Receiving Endovascular Treatment.

This study aimed to investigate the association between cerebral small vessel disease (CSVD) burden and infarct growth rate (IGR) in patients with large vessel occlusion (LVO) stroke who underwent endovascular treatment (EVT). A retrospective analysis was conducted on a cohort of 495 patients with anterior circulation stroke who received EVT. CSVD burden was assessed using a CSVD score based on neuroimaging features. IGR was calculated from diffusion-weighted imaging (DWI) lesion volumes divided by the time from stroke onset to imaging. Clinical outcomes included stroke progression and functional outcomes at 3 months. Multivariate analyses were performed to assess the relationship between CSVD burden, IGR, and clinical outcomes. The fast IGR group had a higher proportion of high CSVD scores than the slow IGR group (24.4% vs. 0.8%, p < 0.001). High CSVD burden was significantly associated with a faster IGR (odds ratio [95% confidence interval], 26.26 [6.26-110.14], p < 0.001) after adjusting for confounding factors. High CSVD burden also independently predicted stroke progression and poor functional outcomes. This study highlights a significant relationship between CSVD burden and IGR in LVO stroke patients undergoing EVT. High CSVD burden was associated with faster infarct growth and worse clinical outcomes.

Abstract 300: An Opportunity for Awareness: The International Academy of Emergency Medical Dispatch's Stroke Diagnostic Tool is Predictive, but Underutilized, for Hospital Confirmed Large Vessel Occlusion Strokes

Background: Accurate identification of ischemic stroke from large vessel occlusion (LVO) by 9-1-1 professionals can facilitate prompt patient transfer to stroke centers that perform endovascular thrombectomy. We sought to determine the proportion of LVO stroke patients that were evaluated using the Medical Priority Dispatch System's (MPDS) Stroke Diagnostic Tool (SDxT). Methods: Structured, retrospective review of our institution’s stroke registry, EMS Records, and dispatch codes between January 1, 2019 and November 30, 2022. Inclusion: Adult (age &gt;17), accessed the 9-1-1 system and transported by a ground EMS agency for an acute stroke. Exclusion: age &lt;18, pregnant, incarcerated, cases with missing 9-1-1 data, and intracranial hemorrhage. Two trained/monitored abstractors, blinded to the study purpose, used a standardized data collection tool/dictionary to extract data. Data included MPDS codes, SDxT outcome, EMS care, demographics, hospital NIHSS score, advanced imaging, tPA administration, and mechanical thrombectomy. Primary outcome: the proportion of LVO cases that had an acute stroke (28 protocol) dispatch code. Secondary outcome: the proportion of LVO cases that that a SDxT score indicating “strong or clear evidence of a stroke”. We report proportions and 95% CI's as appropriate. Results: 60 patients met inclusion/exclusion criteria. 11/60, 18.3 % (95%CI= 10.4, 30) of the patients had complete data and a LVO. 54% were male, the median (IQR) age was 69.5 (61.3-77.5), and the median (IQR) NIHSS was 16 (5-19.75). Primary outcome: 45.5 % (95% CI= 21.3.72.0) of the LVO’s were coded as an Acute Stroke by the 9-1-1 center. Of those, 3/5 utilized the stroke diagnostic tool, all 3 of these were determined to have "Clear Evidence of Stroke". Limitations: Retrospective, unlinked data, small number of LVO's. Conclusion: When utilized, the SDxT correctly identified all LVO’s. There is an opportunity to increase awareness and utilization of the SDxT by 9-1-1 centers. Future research should focus on identifying barriers to stroke recognition and provide additional tools to address the real-life challenges our 9-1-1 communications specialists face when rapidly assessing for an acute stroke over the phone.

Abstract 066: Mechanical Thrombectomy Access in Africa: A Mission Thrombectomy (MT‐2020 Plus) MT‐GLASS Study Sub‐Analysis

Introduction Despite the well‐established potent benefit of mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke, access to MT remains low globally, particularly in Africa. We compared the access to MT in Africa versus access in other regions of the globe. Methods Mission Thrombectomy conducted a survey in 75 countries between November 22, 2020, and February 28, 202 to assess the access to mechanical thrombectomy and its determinants. Mechanical thrombectomy access (MTA) was defined as the estimated proportion of patients with LVO receiving MT annually. The current MT operator availability was defined as ([current MT operators x 50/current annual number of estimated thrombectomy‐eligible LVOs] x 100) and the current MT center availability was defined as ([current MT centers x 150/current annual number of estimated thrombectomy‐eligible LVOs] x 100). Baseline survey responses in Africa versus the rest of the world were summarized using descriptive statistics. Between group differences in baseline characteristics were evaluated using the Wilcoxon rank‐sum test Results Of all 61 countries included in the final analysis, 14.8% (n=9) were from the African continent. Median MT access in Africa (0.4%) was about 10% of that of the rest of the world (4.9%). Country‐level summary characteristics of different determinants of MT access in Africa vs the rest of the world are presented in Table 1. Less than 50% of African countries (44.4%) have prehospital medical services, compared to 84.6% in the rest of the world (p‐value for comparison =0.007). In generalized linear models, LVO stroke patients in Africa had 90% lower odds of MT access when compared to the rest of the world (OR 0.10, 95%CI 0.04‐0.22). Conclusion Access to MT in Africa is extremely low and far below that of other regions of the globe. Public health interventions must be prioritized to increase access to MT in the continent of Africa.

Abstract 278: Patterns of Mechanical Thrombectomy for Stroke Before and After the 2015 Pivotal Trials:5 Years Follow‐up

Introduction The 2015 American Heart Association Guidelines recommended mechanical thrombectomy with stent‐retriever devices. A prior published analysis of national trends after one year in mechanical thrombectomy use and outcomes for stroke before and after publication of the 2015 US guideline update showed improved functional outcomes and lower peri‐procedural mortality. We analyze the national trends in mechanical thrombectomy use and outcomes for stroke five years after publication of the US guideline update. Methods We analyzed the National Inpatient Sample from 2012‐2019. ICD‐9 and ICD‐10 codes identified Ischemic stroke and mechanical thrombectomy patients. Similar to the previous study, discharge to home was the primary efficacy outcome measure in this study since it strongly correlates with mild degree of disability at discharge and 3 months post‐stroke. Safety outcomes include in‐hospital medical complications and mortality. We utilized multivariate logistic regression to assess outcomes. Results From 2012‐2019, 4,003,405 individuals with a diagnosis of ischemic stroke were recorded, 103,605 (2.6%) of which were treated with mechanical thrombectomy, proportionally increased from 4,910/452,905 (1.1%) in 2012 to 26,365/552,780 (4.8%) in 2019. The proportion of endovascular thrombectomy performing hospitals nearly doubled during the study period from 2012 (295/4,378; 6.7%) to 2019 (582/4,568; 12.7%). Odds of a mild disability outcome increased from 16% to 20%, OR 0.65 (0.57, 0.74), while mortality decreased from 15% to 12%, OR 0.69 (0.61, 0.78). Compared with 2012‐2014, the 2015‐2019 cohort showed increased odds of ICH and shock while the odds of DVT, pulmonary embolism, pneumonia, and UTI were significantly lower. The presence of septicemia, shock, and cardiac arrest were unchanged. Conclusion The number of large vessel occlusion stroke patients receiving mechanical thrombectomy treatment in the United States is increasing rapidly each year after the 2015 US guideline update. As the use of mechanical thrombectomy expands, included patients have more medical complications at baseline, but experience fewer complications, peri‐procedural mortality and overall improved outcomes.

Abstract 044: Single‐Step Intracranial Angioplasty followed by Atlas Stent Deployment Through Mini Trek Rx Balloon

Introduction The current FDA approved intracranial stent delivery system requires a multi‐step deployment involving the use of exchange length microwire (ELW), typically 0.014‐inch 300 cm wire, to navigate the balloon catheter, which is then exchanged, after performing the angioplasty, over the ELW to a 0.017’ microcatheter that is used to deploy the intracranial stent. Herein, we describe a single‐step approach to deploy Neuroform Atlas stent (Stryker Neurovascular, Fremont, CA) which is a hybrid laser‐cut, nitinol self‐expanding stent without the need for ELW or lesion re‐access using MINI TREK RX (Abbott Vascular, Inc., Santa Clara, CA, USA) semi compliant balloon adapted from cardiovascular literature which showed a pre‐dilation angioplasty capability in coronary stenotic lesions. Methods We performed a retrospective review of prospectively maintained mechanical thrombectomy (MT) databases of 2 comprehensive stroke centers between November 2020, and May 2023. The inclusion criteria were consecutive large vessel occlusion stroke patients in whom single step MINI TREK RX balloon angioplasty followed by Neuroform Atlas intracranial stent deployment was performed without using ELW (Figure‐1). There was no restriction on time from last known well (TLKW) to MT. During the standard mechanical thrombectomy procedure, intracranial atherosclerotic disease/ significant stenotic lesion was suspected by immediate re‐occlusion/ persistent occlusion following at least 1 thrombectomy pass. This is followed by pursuing intracranial angioplasty and stent placement as a rescue recanalization measure. The primary outcome was successful reperfusion defined as a Modified Treatment in Cerebral Ischemia (mTICI) score of 2b or greater at the end of the procedure. Secondary outcomes included NIH Stroke Scale (NIHSS) at 24 hours, NIHSS at discharge, median modified Rankin Scale (mRS) score at discharge and at 90‐day follow‐up. Safety measures included rates of symptomatic intracranial hemorrhage (sICH) and mortality at 90 days. Results Among 9 patients who met our criteria, the median age was 63 (51‐69.5) years and 55.6% were females. Most patients had left middle cerebral artery‐ M1 occlusion (66.7%) and one third received thrombolytics (33.3%). All patients underwent the single‐step approach and achieved successful reperfusion (m TICI 2b‐3) with 2 median number of passes. The median NIHSS was reduced from 13.5 (8.5‐17.5) at baseline to 4 (1‐16.5) at discharge. In addition, median mRS was 1 (1‐3.5) at discharge and 3 (3‐4) at 90 days. None of the patients included in this series had sICH while only one patient with basilar artery occlusion underwent ventriculostomy during hospital stay and was sedated/intubated and died. Conclusion This preliminary experience showed technical feasibility and success of using single‐ step to deploy Neuroform Atlas stent after performing angioplasty using MINI TREK RX without the need for ELW or lesion re‐access. Prospective studies with larger sample size and long‐term clinical follow‐up are warranted to confirm these results.

Large vessel occlusion prediction scale thresholds that are sensitive for DAWN Trial patients

Background Large vessel occlusion (LVO) prediction scales are used to triage prehospital suspected stroke patients with a high probability of LVO stroke to endovascular therapy centers. The sensitivities of these scales in the 6-to-24-h time window are unknown. Higher scale score thresholds are typically less sensitive and more specific. Knowing the highest scale score thresholds that remain sensitive could inform threshold selection for clinical use. Sensitivities may also vary between left and right-sided LVOs. Methods LVO prediction scale scores were retrospectively calculated using the National Institutes of Health Stroke Scale (NIHSS) scores of patients enrolled in the DAWN Trial. All patients had last known well times between 6 and 24 h, NIHSS scores ≥ 10, intracranial internal carotid artery or proximal middle cerebral artery occlusions, and mismatches between their clinical severities and infarct core volumes. Scale thresholds with sensitivities ≥ 85% were identified, along with scores ≥ 5% more sensitive for left or right-sided LVOs. Specificities could not be calculated because all patients had LVOs. Results A total of 201 out of 206 patients had the required NIHSS subitem scores. CPSS = 3, C-STAT ≥ 2, FAST-ED ≥ 4, G-FAST ≥ 3, RACE ≥ 5, and SAVE ≥ 3 were the highest thresholds that were still 85% sensitive for DAWN Trial LVO stroke patients. RACE ≥ 5 was the only typically used score threshold more sensitive for right-sided LVOs, though similar small differences were seen for other scales at higher thresholds. Conclusions Our findings likely represent the maximum sensitivities of the LVO prediction scales tested for ideal thrombectomy candidates in the 6-to-24-h time window because NIHSS scores were documented in hospitals during a clinical trial rather than in the prehospital setting. Patients with NIHSS scores &lt; 10 or more distal LVOs would lower sensitivities further. Selecting even higher scale thresholds for LVO triage would lead to many missed LVO strokes.

Yield of Whole Body Computed Tomography in Hyper-Acute Stroke Patients With Large Vessel Occlusion.

In the majority of cases, large vessel occlusion (LVO) in ischemic stroke patients has an embolic origin. Systemic embolism can occur simultaneously with brain thrombosis. This retrospective study evaluated the frequency and locations of systemic embolism in LVO stroke patients receiving revascularization therapy. In our facility, we use contrast-enhanced computed tomography (CE-CT) to assess suspected stroke patients and routinely perform CE-CT from the chest to the abdomen after brain CT angiography to rule out contraindications like aortic dissection and trauma for thrombolysis. Systemic embolism is also assessed using these images, while myocardial infarction is evaluated based on electrocardiograms and laboratory findings. Other relevant clinical features of each patient are also analyzed. In total, 612 consecutively admitted stroke patients and 32 LVO patients who underwent revascularization therapy were included in the present study. Systemic embolism was identified in four patients (13%). The spleen was the most commonly affected organ, followed by the heart, kidneys, limbs, and lungs. All four patients with systemic embolism exhibited LVO resulting from embolism as the underlying mechanism. Systemic embolism was observed in 13% of our LVO patients, all of whom had LVO of embolic origin.

Delay in hospital presentation is the main reason large vessel occlusion stroke patients do not receive intravenous thrombolysi.

Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the mainstays of treatment for large vessel occlusion stroke (LVOS). Prior studies have examined why patients have not received IVT, the most cited reasons being last-known-well (LKW) to hospital arrival of>4.5hours and minor/resolving stroke symptoms. Given that LVOS patients typically present moderate-to-severe neurologic deficits, these patients should be easier to identify and treat than patients with minor strokes. This investigation explores why IVT was not administered to a cohort of LVOS patients who underwent EVT. This is an analysis of the Optimizing the Use of Prehospital Stroke Systems of Care (OPUS-REACH) registry, which contains patients from 9 endovascular centers who underwent EVT between 2015 and 2020. The exposure of interest was the receipt of intravenous thrombolysis. Descriptive summary statistics are presented as means and SDs for continuous variables and as frequencies with percentages for categorical variables. Two-sample t tests were used to compare continuous variables and the chi-square test was used to compare categorical variables between those who received IVT and those who did not receive EVT. Two thousand forty-three patients were included and 60% did not receive IVT. The most common reason for withholding IVT was LKW to arrival of>4.5 (57.2%). The second most common contraindication was oral anticoagulation (15.5%). On multivariable analysis, 2 factors were associated with not receiving IVT: increasing age (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.78-0.93) and increasing time from LKW-to hospital arrival (OR 0.45 95% CI 0.46-0.49). Like prior studies, the most frequent reason for exclusion from IVT was a LKW to hospital presentation of>4.5hours; the second reason was anticoagulation. Efforts must be made to increase awareness of the time-sensitive nature of IVT and evaluate the safety of IVT in patients on oral anticoagulants.

Radiomics features on computed tomography reflect thrombus histological age prior to endovascular treatment of acute ischemic stroke

PurposeTo investigate the role of radiomics features in thrombus age identification and establish a CT-based radiomics model for predicting thrombus age of large vessel occlusion stroke patients. MethodsWe retrospectively reviewed patients with middle cerebral artery occlusion receiving mechanical thrombectomy from July 2020 to March 2022 at our center. The retrieved clots were stained with Hematoxylin and Eosin (H&E) and determined as fresh or older thrombi based on coagulation age. Clot-derived radiomics features were selected by least absolute shrinkage and selection operator (LASSO) regression analysis, by which selected radiomics features were integrated into the Rad-score via the corresponding coefficients. The prediction performance of Rad-score in thrombus age was evaluated with the area under the curve (AUC) of receiver operating characteristic (ROC) curve analysis. ResultsA total of 104 patients were included in our analysis, with 52 in training and 52 in validation cohort. Older thrombi were characterized with delayed procedure time, worse functional outcome and marginally associated with more attempts of device. We extracted 982 features from NCCT images. Following T test and LASSO analysis in training cohort, six radiomics features were selected, based on which the Rad-score was generated by the linear combination of features. The Rad-score showed satisfactory performance in distinguishing fresh with older thrombi, with the AUC of 0.873 (95 %CI: 0.777-0.956) and 0.773 (95 %CI: 0.636-0.910) in training and validation cohort, respectively. ConclusionThis study established and validated a CT-based radiomics model that could accurately differentiate fresh with older thrombi for stroke patients receiving mechanical thrombectomy.

A Shorter Door-In-Door-Out Time Is Associated with Improved Outcome in Large Vessel Occlusion Stroke.

Introduction: Endovascular thrombectomy (EVT) significantly improves outcomes in large vessel occlusion stroke (LVOS). When a patient with a LVOS arrives at a hospital that does not perform EVT, emergent transfer to an endovascular stroke center (ESC) is required. Our objective was to determine the association between door-in-door-out time (DIDO) and 90-day outcomes in patients undergoing EVT. Methods: We conducted an analysis of the Optimizing Prehospital Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH) registry of 2,400 LVOS patients treated at nine ESCs in the United States. We examined the association between DIDO times and 90-day outcomes as measured by the modified Rankin scale. Results: A total of 435 patients were included in the final analysis. The mean DIDO time for patients with good outcomes was 17 minute shorter than patients with poor outcomes (122 minutes [min] vs 139min, P = 0.04). Absolute DIDO cutoff times of ≤60min, ≤90min, or ≤120min were not associated with improved functional outcomes (46.4 vs 32.3%, P = 0.12; 38.6 vs 30.6%, P = 0.10; and 36.4 vs 28.9%, P = 0.10, respectively). This held true for patients with hyperacute strokes of less than four-hour onset. Lower baseline National Institutes of Health Stroke Scale (NIHSS) score (11.9 vs 18.2, P = <.001) and younger age (62.5 vs 74.9years (P < .001) were associated with improved outcomes. On multiple regression analysis, age (odds ratio [OR] 1.71, 95% confidence interval [CI] 1.45-2.02) and baseline NIHSS score (OR 1.67, 95% CI 1.42-1.98) were associated with improved outcomes while DIDO time was not associated with better outcome (OR 1.13, 95% CI 0.99-1.30). Conclusion: Although the DIDO time was shorter for patients with a good outcome, this was non-significant in multiple regression analysis. Receipt of intravenous thrombolysis and time to EVT were not associated with better outcomes, while male gender, lower age, arrival by private vehicle, and lower NIHSS score portended better outcomes. No absolute DIDO-time cutoff or modifiable factor was associated with improved outcomes for LVOS. This study underscores the need to streamline DIDO times but not to set an artificial DIDO time benchmark to meet.

Impact of ongoing intravenous thrombolysis until completion of endovascular treatment in large vessel occlusion stroke patients.

Recent studies have implied that ongoing intravenous thrombolysis (IVT) during endovascular treatment (ET) improves functional outcomes in patients who have undergone stroke caused by a large vessel occlusion (LVO). In this study, we investigated the effect of ongoing IVT until completion of ET on procedure duration, first-pass thrombectomy rate, and periprocedural complications. We analyzed patients from the German Stroke Registry-Endovascular Treatment dataset, collected between June 2015 and December 2021. Primary outcomes were modified Rankin Scale (mRS) score after 3 months and achievement of a Thrombolysis In Cerebral Infarction (TICI) score of 2b-3. Secondary parameters included ET duration, first-pass thrombectomy, and periprocedural complications. Of the 13,082 patients in the dataset, 1,639 met the study inclusion criteria. A total of n = 317 patients (19.3%) underwent ongoing IVT until completion of ET, while IVT was completed prior to ET in 1,322 patients (80.7%). Ongoing IVT was associated with higher rates of achievement of an mRS score of 0-2 (or a back-to-baseline) after 3 months [odds ratio (OR) 1.53; 95% confidence interval (CI) 1.08-2.17]. Furthermore, ongoing IVT was predictive of achievement of a TICI score of 2b-3 (OR 1.37; 95% CI 1.03-1.83) and of first-pass thrombectomy (OR 2.07; 95% CI 1.51-2.84), while reducing the rate of peri-interventional complications (OR 0.64; 95% CI 0.44-0.94) and reducing ET duration by 24 min [β = -24.35; 95% CI -32.92-(-15.79)]. Our findings suggest that ongoing IVT until ET completion has a favorable impact on both clinical and angiographic outcomes, as well as on periprocedural conditions, regardless of the overall time intervals involved. Therefore, rapid ET after IVT should be sought in order to take advantage of the additive effect of ongoing IVT during ET. Future studies should consider IVT timing in the context of ET as a potential confounder and treatment target.

Mechanical Thrombectomy in Cervical Artery Dissection-Related Stroke

Cervical artery dissection (CeAD) causing a large vessel occlusion (LVO) stroke might represent a procedural challenge for mechanical thrombectomy (MT) impacting on its effects. The aim of the present study was to analyze safety, reperfusion rates and clinical outcome of CeAD patients treated by MT and compare these results with those obtained in non-CeAD patients. All consecutive LVO stroke patients undergoing MT between June 2015 and June 2021 at our University Stroke Center were analyzed. Baseline and procedural characteristics, recanalization rates, adverse events, and functional outcome of CeAD patients were compared with non-CeAD patients. MT was performed on 375 patients, 20 (5.3%) were diagnosed with CeAD. These patients were younger (52.9±7.8 vs 72.5±12.9 years, p<0.001), and showed lower rates of cardiovascular risk factors. In CeAD patients, tandem occlusions were more frequent (65.0% vs 14.4%, p<0.001), groin to reperfusion time was longer (93.6 ± 34.9 vs 68.3 ± 50.2 minutes, p=0.01) and general anesthesia was more frequently utilized (70.0% vs 27.9%, p<0.001). Recanalization rates (TICI 2b-3: 100.0% vs 88.5%) and MT-related adverse events (10.0% vs 10.7%) did not differ between the groups, while functional outcome was better in CeAD patients (mRS 0-2 at 3 months: 85.0% vs 62.0%, p=0.038). Although CeAD represents a procedural challenge, MT constitutes a safe and effective treatment for CeAD patients with LVO stroke.

June 2023 Stroke Highlights.

HomeStrokeVol. 54, No. 6June 2023 Stroke Highlights Free AccessIn BriefPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessIn BriefPDF/EPUBJune 2023 Stroke Highlights Nicole B. Sur Nicole B. SurNicole B. Sur Correspondence to: Nicole B. Sur, MD, Department of Neurology, Stroke Division, University of Miami Miller School of Medicine, 1120 NW 14th St, CRB 1358, Miami, FL 33136. Email E-mail Address: [email protected] Search for more papers by this author Originally published22 May 2023https://doi.org/10.1161/STROKEAHA.123.043538Stroke. 2023;54:1463is related toInfarcts in a New Territory: Insights From the ESCAPE-NA1 TrialEffect of Imaging Selection Paradigms on Endovascular Thrombectomy Outcomes in Patients With Acute Ischemic StrokeFive-Year Stroke Risk and Its Predictors in Asymptomatic Moyamoya Disease: Asymptomatic Moyamoya Registry (AMORE)Five-Year Stroke Risk and Its Predictors in Asymptomatic Moyamoya Disease: Asymptomatic Moyamoya Registry (AMORE)Moyamoya disease is characterized by progressive stenosis of the distal intracranial carotid arteries or proximal middle and anterior cerebral arteries, resulting in dilation of the perforator arteries and development of deep collateral pathways. Stroke—both hemorrhagic and ischemic—is a known consequence of moyamoya disease. The long-term risk of cerebrovascular events in asymptomatic moyamoya disease, however, is not well characterized. In this multicenter prospective cohort study, investigators followed 103 patients with asymptomatic moyamoya disease (189 hemispheres) in Japan with the goal of evaluating the 5-year risk and predictors of stroke. The average age was 44 years, female-to-male ratio was 2:1, and family history of moyamoya disease was found in 20% of cases. The 5-year risk of stroke in this cohort was 6.8% (7 individuals), with an annual risk of 1.4% per person and 0.8% per hemisphere. Of the 7 cases of stroke, 6 were hemorrhagic and 1 was ischemic, with relatively poor outcomes in the individuals with hemorrhagic stroke. There were no stroke events in the 5-year follow-up period in the 39 individuals categorized as questionable moyamoya. When evaluated hemisphere by hemisphere, grade 2 choroidal anastomosis (most dilated and peripherally running perforators) and presence of microbleeds on brain imaging were significant predictors for stroke. The annual risk of hemorrhagic stroke was elevated in patients with grade 2 choroidal anastomoses (3.2%) compared with those without (0.4%). This study highlights the high risk of 5-year stroke events in patients with asymptomatic moyamoya disease and radiographic predictors of high-risk cases. Although the study is ongoing with the long-term goal of assessing 10-year outcomes, these interim results provide valuable insight that may influence stroke prevention strategies. See p 1494.Infarcts in a New Territory: Insights From the ESCAPE-NA1 TrialThe ESCAPE-NA1 trial (Safety and Efficacy of Nerinetide [NA-1] in Subjects Undergoing Endovascular Thrombectomy for Stroke) was a clinical trial of patients with large vessel occlusion stroke within 12 hours of onset who underwent endovascular thrombectomy and were randomized to receive intravenous nerinetide versus placebo, resulting in no significant difference in modified Rankin Scale score of 0 to 2 at 90 days between both groups. In this substudy of the ESCAPE-NA1 cohort (n=1092), investigators sought to identify the rate, characteristics, and outcomes of individuals with infarcts in a new territory (INT), after endovascular thrombectomy. The overall cohort comprised patients with severe anterior circulation stroke (median age, 70.8 years; 49.7% women), of whom 60% received intravenous thrombolysis and half received nerinetide. INT occurred in 9.4% of the cohort: 77% were >2 mm, 56.5% were single INTs, 43.5% were multiple INTs, and the anterior cerebral artery territory was most affected. There was no association between INT and procedural catheter type or number of passes. Patients with INT had significantly lower chance of functional independence at 90 days, larger infarct volumes, and higher mortality compared with the no-INT group. Radiographic and symptomatic intracerebral hemorrhage was similar across both groups, and there was no effect of thrombolysis or nerinetide administration on INT. This study illustrates how common INTs are after endovascular therapy. Given the association with worse functional outcomes, preventing INTs may be an important strategy for improving stroke outcomes after thrombectomy. See p 1477Effect of Imaging Selection Paradigms on Endovascular Thrombectomy Outcomes in PATIENTS WITH ACUTE ISCHEMIC STROKEThe decision-making process for the use of endovascular thrombectomy (EVT) in patients with large vessel occlusion stroke is largely dependent on acute brain imaging to rule out hemorrhagic stroke (or other causes), assess for signs of ischemia, and identify the affected vessel. With advanced imaging technology, such as perfusion imaging that leverages artificial intelligence to estimate ischemic core and penumbra volumes, the acute stroke imaging paradigms have become quite complex. Some studies suggest, however, that these paradigms might be too selective and may exclude patients who might otherwise benefit from EVT. In this study utilizing pooled data from 2 large EVT trials in China (n=1182), investigators compared outcomes of acute large vessel occlusion stroke patients who presented in early (0–6 hours) versus extended (6–24 hours) window and had basic imaging (noncontrast head computed tomography with or without computed tomography angiography) versus advanced imaging (basic imaging plus magnetic resonance imaging or computed tomography perfusion) to decide on candidacy for EVT. In the early window, most patients underwent basic imaging, whereas in the advanced window, most patients had advanced imaging. There were no differences in time metrics in the early window; however, patients in the extended window group had shorter onset-to-puncture times with basic imaging compared with advanced imaging. After adjustment, there was no significant difference in functional independence at 90 days, mortality, or any hemorrhage between basic versus advanced imaging in either the early or extended treatment windows. Similar to prior trials in North America and Europe, this study suggests that simpler imaging paradigms for selection of EVT candidates in patients with acute large vessel occlusion stroke do not significantly impact clinical outcomes and might be sufficient for deciding on whether to proceed with thrombectomy. See p 1569FootnotesCorrespondence to: Nicole B. Sur, MD, Department of Neurology, Stroke Division, University of Miami Miller School of Medicine, 1120 NW 14th St, CRB 1358, Miami, FL 33136. Email [email protected]miami.edu Previous Back to top Next FiguresReferencesRelatedDetailsRelated articlesInfarcts in a New Territory: Insights From the ESCAPE-NA1 TrialNishita Singh, et al. Stroke;0Effect of Imaging Selection Paradigms on Endovascular Thrombectomy Outcomes in Patients With Acute Ischemic StrokeJian Miao, et al. Stroke. 2023;54:1569-1577Five-Year Stroke Risk and Its Predictors in Asymptomatic Moyamoya Disease: Asymptomatic Moyamoya Registry (AMORE)Satoshi Kuroda, et al. Stroke. 2023;54:1494-1504 June 2023Vol 54, Issue 6 Advertisement Article InformationMetrics © 2023 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.123.043538PMID: 37216449 Originally publishedMay 22, 2023 PDF download Advertisement

Factors associated with door-in-door-out times in large vessel occlusion stroke patients undergoing endovascular therapy

IntroductionIn the management of large vessel occlusion stroke (LVOS), patients are frequently evaluated first at a non-endovascular stroke center and later transferred to an endovascular stroke center (ESC) for endovascular treatment (EVT). The door-in-door-out time (DIDO) is frequently used as a benchmark for transferring hospitals though there is no universally accepted nor evidenced-based DIDO time. The goal of this study was to identify factors affecting DIDO times in LVOS patients who ultimately underwent EVT. MethodsThe Optimizing Prehospital Use of Stroke Systems of Care-Reacting to Changing Paradigms (OPUS-REACH) registry is comprised of all LVOS patients who underwent EVT at one of nine endovascular centers in the Northeast United States between 2015 and 2020. We queried the registry for all patients who were transferred from a non-ESC to one of the nine ESCs for EVT. Univariate analysis was performed using t-tests to obtain a p value. A priori, we defined a p value of <0.05 as significant. Multiple logistic regression was conducted to determine the association of variables to estimate an odds ratio. Results511 patients were included in the final analysis. The mean DIDO times for all patients was 137.8 min. Vascular imaging and treatment at a non-certified stroke center were associated with longer DIDO times by 23 and 14 min, respectively. On multivariate analyses, the acquisition of vascular imaging was associated with 16 additional minutes spent at the non-ESC while presentation to a non-stroke certified hospital was associated with 20 additional minutes spent at the transferring hospital. The administration of intravenous thrombolysis (IVT) was associated with 15 min less spent at the non-ESC. DiscussionVascular imaging and non-stroke certified stroke centers were associated with longer DIDO times. Non-ESCs should integrate vascular imaging into their workflow as feasible to reduce DIDO times. Further work examining other details regarding the transfer process such as transfer via ground or air, could help further identify opportunities to improve DIDO times.