Occlusion Acute Ischemic Stroke Research Articles

Abstract TP62: Computed Tomography Perfusion Infarct Measurement Compared to Diffusion-Weighted Magnetic Resonance Imaging in Patients Without Revascularization of Anterior Circulation, Large Artery Occlusions

Introduction: The CT Perfusion (CTP) parameter Time-Maximum greater than 6 seconds (Tm > 6s) represents delayed blood flow in critically hypoperfused brain tissue. Though Tm > 6s is expected to accurately represent infarct size in stroke patients who do not undergo revascularization, some brain tissue at risk may not progress to infarction and recover spontaneously (“benign oligemia”). We sought to investigate the relationship between Tm > 6s and the gold standard of final infarct volume on DWI MRI in patients with anterior circulation, large artery occlusion (LAO) acute ischemic stroke (AIS) who do not achieve reperfusion. Hypothesis: Critically hypoperfused brain tissue, as represented by CTP Tm > 6s, overestimates final infarct volume on DWI MRI in at least 50% of patients with ICA or proximal MCA occlusions without angiographic revascularization. Methods: From a large healthcare system’s stroke network database, we conducted a retrospective analysis comparing delayed perfusion volume (Tm > 6s; RAPID iSchemaView) on CTP and DWI MRI volume (ADC < 620cc; RAPID iSchemaView) in patients with ICA, M1, or M2 occlusions between November 2016 and June 2017 not treated with acute reperfusion therapy, or without angiographic revascularization (TICI 0). Results: Over an 8-month period, 19 cases were identified with baseline CTP, follow-up MRI, and no reperfusion of an ICA, M1, or M2 occlusion. Mean age was 65.8 years old and median NIHSS was 8. Mean duration from last known well time to CTP and MRI was 4.4 and 22.8 hours, respectively. Three patients were treated with IV TPA and endovascular therapy, 4 received only endovascular therapy, and 12 did not receive IV TPA nor endovascular intervention. The Tm >6s volume was greater than follow-up DWI MRI volume in 13/19 (68%) cases by an average of 37.4cc. Conclusions: Critically hypoperfused brain tissue on CTP, represented by Tm > 6s, may spontaneously recover in patients with proximal, LAO AIS. Establishing CTP parameters that delineate ischemic penumbra from benign oligemia will aid in identifying the volume of ischemic tissue truly at risk for infarction in LAO patients.

Abstract WP248: Insights Into Improving Care: Established Infarct and No Large Vessel Occlusion Are the Major Causes to Forego Endovascular Therapy Following Transfer

Introduction: Endovascular therapy (ET) has emerged as the standard of care for large vessel occlusion (LVO) acute ischemic stroke (AIS) following the positive outcomes from multiple recent randomized trials. This has resulted in an increase in the number of LVO AIS patient transfers to comprehensive stroke centers (CSC). Not all transfers result in ET, and futile transfers may overload CSCs with poor cost benefit ratio. Thus an analysis of the major reasons to forego ET is warranted. Hypothesis: The major causes to forego ET in LVO AIS patients transferred for treatment in an metropolitan setting are a product of the local stroke systems of care and causes that may be mediated with appropriate imaging and EMS triage protocols will be identified. Methods: A retrospective analysis of data prospectively collected data between January 1, 2015, and July 31, 2017 was performed on 171 patients whom were transferred from outside hospitals (OSH) to a CSC in a metropolitan area. Of these patients, 63 (37%) were deemed ineligible for ET. The causes to forego ET in these patients were identified and cross referenced with factors that could be changed such as imaging protocols, transfer times, and proximity to a CSC. Results: The major causes to forego ET were established infarct due to intra-transfer ASPECTS decay (36%) and no LVO (29%). Other causes included: patient too mild or clinically improved (22%), post-tPA hemorrhage (5%), outside time window or randomized to medical management (3%), and other, such as heart attack, seizure, or gastrointestinal bleed (5%). Of the no LVO cohort, 14/18 patients (78%) had no CTA imaging until CSC arrival. The established infarct cohort had a median OSH arrival to CSC arrival time interval of 165 minutes (IQR=130-229.5). Proximity to a CSC from the OSHs in the study ranged from 1 to 9.6 miles with a travel time of 7 to 30 minutes. Conclusions: Development of established infarct and no LVO were major causes of no ET for transfer patients. These can be mediated by stroke system changes to minimize patient transfers, such as EMS triage to CSC for LVO, with minimal impact on initial arrival time in this urban setting. In addition, the implementation of timely computed tomography angiography (CTA) imaging at OSHs should help reduce futile transfers.

Abstract TMP71: Non-Enhanced Computed Tomography to Computed Tomography Angiogram Performance Times: Telestroke versus Bedside Neurologists

Introduction: The 2015 AHA/ASA Stroke Management Guidelines strongly recommend that if endovascular therapy is contemplated, a Computed Tomography Angiogram (CTA) be included in the initial imaging evaluation. Telestroke neurologists evaluating patients at Non-endovascular Stroke Centers (NESCs) are mostly focused on achieving quick door-to-needle (DTN) intravenous (IV) tPA times, not prompt CTA performance times to facilitate expeditious endovascular treatment for large vessel occlusion (LVO) acute ischemic stroke (AIS) patients. Hypothesis: The Non-Enhanced Computed Tomography (NECT) to CTA time interval for LVO patients evaluated by telestroke neurologists at NESCs is significantly longer than for LVO patients initially evaluated at Endovascular Stroke Centers (ESCs). Methods: From a large healthcare system’s stroke network database, we conducted a retrospective analysis comparing the NECT to CTA time performance interval for consecutive patients initially presenting to any one of 23 different hospitals or freestanding emergency departments who were identified as having an LVO AIS and met candidacy for ESC transfer. Results: Over 7 months, we identified 71 LVO cases initially presenting to one of 21 NESCs covered by teleneurologists and 62 cases from one of 2 ESCs covered by bedside neurologists. After removing the outliers (>95th percentile for ESC cases and >90th percentile for NESC cases), we retained 64 cases from NESCs and 59 from ESCs for our analysis. NECT to CTA times were significantly longer at the NESCs than at the ESCs, with NECT to CTA means of 27.94 minutes (SD: 24.93, IQR: 41.5) for NESC cases versus 10 minutes (SD: 3.29, IQR:4) for ESC cases (Kolmogorov-Smirnov test asymptotic p-value 0.0001), Conclusion: The NECT to CTA performance time interval for LVO AIS patients evaluated at NESCs by telestroke neurologists is significantly longer than for LVO AIS patients evaluated at ESCs. These data suggest that steps should be taken to ensure that NECT to CTA time intervals receive the same attention as DTN IV tPA times in assessing overall telestroke neurologist process performance.

Abstract WP48: Computed Tomography Perfusion Core Infarct Measurement Compared to Diffusion-Weighted Magnetic Resonance Imaging in Patients With Revascularization of Anterior Circulation, Large Artery Occlusions

Introduction: Automated CT Perfusion (CTP) technology offers the potential to distinguish irreversibly damaged tissue from “at-risk,” potentially salvageable tissue. Regional Cerebral Blood Flow (CBF) < 30% has been identified as a good predictor of infarct core on CTP. Randomized trials investigating mechanical thrombectomy for large artery occlusion (LAO) acute ischemic stroke (AIS) have excluded patients with large core infarcts. We investigated the relationship between infarct core, as predicted by CTP, compared to the gold standard of DWI MRI, after revascularization of a proximal, anterior circulation, LAO AIS. Hypothesis: CBF < 30% overestimates core infarct size compared to DWI MRI in at least one-third of patients with occlusions of the internal carotid artery (ICA) or middle cerebral artery (MCA) M1 or M2 segments treated with endovascular therapy achieving thrombolysis in cerebral infarction (TICI) grade 2b or 3. Methods: From a large healthcare system’s stroke network database, we conducted a retrospective analysis comparing infarct core (CBF < 30%; RAPID iSchemaView) and post-revascularization DWI MRI (ADC < 620cc; RAPID iSchemaView) in patients with ICA, M1, or M2 LAO AIS between November 2016 and June 2017 with TICI 2b or 3 reperfusion. Results: Over an 8-month period, 25 cases were identified with pre-treatment CTP, post-intervention MRI, and TICI 2b/3 revascularization of an ICA, M1, or M2 occlusion. Mean age was 61.1 years old and median NIHSS was 16. Mean duration from last known well time to CTP and MRI was 4.2 and 27.1 hours, respectively. Sixteen patients were treated with IV TPA and endovascular intervention, while 9 underwent only endovascular intervention. Median time to revascularization was 5.6 hours. CTP overestimated infarct size compared to follow-up MRI in 9/25 (36%) cases by an average of 17.8cc. Pearson correlation coefficient between CTP core infarct size and MRI infarct size was non-significant (r = 0.17, p = 0.41). Conclusions: Core infarct size may be overestimated by CTP in a substantial number of patients with revascularization of proximal, anterior circulation LAO AIS. Caution should be exercised when using core infarct estimation of CBF < 30% to exclude patients from endovascular therapy.

Safety and Efficacy of a 3-Dimensional Stent Retriever With Aspiration-Based Thrombectomy vs Aspiration-Based Thrombectomy Alone in Acute Ischemic Stroke Intervention

The treatment effects of individual mechanical thrombectomy devices in large-vessel acute ischemic stroke (AIS) remain unclear. To determine whether the novel 3-dimensional (3-D) stent retriever used in conjunction with an aspiration-based mechanical thrombectomy device (Penumbra System; Penumbra) is noninferior to aspiration-based thrombectomy alone in AIS. This randomized, noninferiority clinical trial enrolled patients at 25 North American centers from May 19, 2012, through November 19, 2015, with follow-up for 90 days. Adjudicators of the primary end points were masked to treatment allocation. Patients with large-vessel intracranial occlusion AIS presenting with a National Institutes of Health Stroke Scale (NIHSS) score of at least 8 within 8 hours of onset underwent 1:1 randomization to 3-D stent retriever with aspiration or aspiration alone. The primary analyses were conducted in the intention-to-treat population. Mechanical thrombectomy using intracranial aspiration with or without the 3-D stent retriever. The primary effectiveness end point was the rate of a modified Thrombolysis in Cerebral Infarction (mTICI) grade of 2 to 3 with a 15% noninferiority margin. Device- and procedure-related serious adverse events at 24 hours were the primary safety end points. Of 8082 patients screened, 198 patients were enrolled (111 women [56.1%] and 87 men [43.9%]; mean [SD] age, 66.9 [13.0] years) and randomized, including 98 in the 3-D stent retriever with aspiration group and 100 in the aspiration alone group; an additional 238 patients were eligible but not enrolled. The median baseline NIHSS score was 18.0 (interquartile range, 14.0-23.0). Eighty-two of 94 patients in the 3-D stent retriever and aspiration group (87.2%) had an mTICI grade of 2 to 3 compared with 79 of 96 in the aspiration alone group (82.3%; difference, 4.9%; 90% CI, -3.6% to 13.5%). None of the other measures were significantly different between the 2 groups. Device-related serious adverse events were reported by 4 of 98 patients in the 3-D stent retriever with aspiration group (4.1%) vs 5 of 100 patients in the aspiration only group (5.0%); procedure-related serious adverse events, 10 of 98 (10.2%) vs 14 of 100 (14.0%). A 90-day modified Rankin Scale score of 0 to 2 was reported by 39 of 86 patients in the 3-D stent retriever with aspiration group (45.3%) vs 44 of 96 patients in the aspiration only group (45.8%). The present study provides class 1 evidence for the noninferiority of the 3-D stent retriever with aspiration vs aspiration alone in AIS. Future trials should evaluate whether these results can be generalized to other stent retrievers. clinicaltrials.gov Identifier: NCT01584609.

Cost-Effectiveness of A Direct Aspiration First Pass Technique (ADAPT) For Thrombectomy Revascularization of Large Vessel Occlusion In Acute Ischemic Stroke (French Health Ministry Prme 16-0020)

To estimate the cost-effectiveness of Direct Aspiration First Pass Technique (ADAPT) versus mechanical thrombectomy with a Stent Retriever (SR) procedure in acute ischemic stroke from a French healthcare providers perspective. The cost-effectiveness study was carried out from a prospective, randomized and multicenter clinical trial including 8 French hospitals. Medical and costs data were collected prospectively relating to the initial procedure from the onset symptom to the best recanalization. The direct medical costs data were collected by micro-costing and analytical accounting. The primary outcome is the modified score Rankin scale (mRS) of independent at three-months (score 0-2). Economic acceptability for community of this new technique is analyzed by measuring the Incremental Cost-Effectiveness Ratio (ICER). Sensitivity analyses were performed. We include 381 eligible patients (192 allocated to ADAPT and 189 allocated to SR) from October 2015 to October 2016. The mean hospital costs were €8372 in ADAPT group, and €8069 in SR group (p-value = 0.49). The percentage of independent patients at 3 months was 55.17 % in ADAPT group, and 62.06 % in SR group (p-value = 0.23). The resulting ICER reveals the need to invest €4389 in order to achieve an additional percentage of independence with the innovative strategy compared to the standard strategy. Based on randomized trial, we demonstrate that ADAPT is not more efficient compared to SR. We will then consider the cost per QALY (mapping mRS into EQ-5D) at 12-months.

Frontline ADAPT therapy to treat patients with symptomatic M2 and M3 occlusions in acute ischemic stroke: initial experience with the Penumbra ACE and 3MAX reperfusion system

BackgroundAfter a series of positive studies for mechanical thrombectomy in large vessel occlusion acute ischemic stroke, the question remains, can symptomatic patients with distal vessel occlusion benefit from mechanical thrombectomy?PurposeTo...

Analyses of thrombi in acute ischemic stroke: A consensus statement on current knowledge and future directions.

Limited data exist on clot composition and detailed characteristics of arterial thrombi associated with large vessel occlusion in acute ischemic stroke. Advances in endovascular thrombectomy and related imaging modalities have created a unique opportunity to analyze thrombi removed from cerebral arteries. Insights into thrombus composition, etiology, physical properties and neurovascular interactions may lead to future advancements in acute ischemic stroke treatment and improved clinical outcomes. Advances in imaging techniques may enhance clot characterization and inform therapeutic decision-making prior to treatment and reveal stroke etiology to guide secondary prevention. Current imaging techniques can provide some information about thrombi, but there remains much to evaluate about relationships that may exist among thrombus composition, occlusion characteristics and treatment outcomes. Improved pathophysiological characterization of clot types, their properties and how these properties change over time, together with clinical correlates from ongoing studies, may facilitate revascularization with thrombolysis and thrombectomy. Interdisciplinary approaches covering clinical, engineering and scientific aspects of thrombus research will be key to advancing the understanding of thrombi and improving acute ischemic stroke therapy. This consensus statement integrates recent research on clots and thrombi retrieved from cerebral arteries and provides a rationale for further analyses, including current opportunities and limitations.

Revascularization of tandem occlusions in acute ischemic stroke: review of the literature and illustrative case.

OBJECTIVE Tandem occlusions continue to represent a major challenge in patients with acute ischemic stroke (AIS). The anterograde approach with proximal to distal revascularization as well as the retrograde approach with distal to proximal revascularization have been reported without clear consensus or standard guidelines. METHODS The authors performed a comprehensive search of the PubMed database for studies including patients with carotid occlusions and tandem distal occlusions treated with endovascular therapy. They reviewed the type of approach employed for endovascular intervention and clinical outcomes reported with emphasis on the revascularization technique. They also present an illustrative case of AIS and concurrent proximal cervical carotid occlusion and distal middle cerebral artery occlusion from their own experience in order to outline the management dilemma for similar cases. RESULTS A total of 22 studies were identified, with a total of 790 patients with tandem occlusions in AIS. Eleven studies used the anterograde approach, 3 studies used the retrograde approach, 4 studies used both, and in 4 studies the approach was not specified. In the studies that reported Thrombolysis in Cerebral Infarction (TICI) grades, an average of 79% of patients with tandem occlusions were reported to have an outcome of TICI 2b or better. One study found good clinical outcome in 52.5% of the thrombectomy-first group versus 33.3% in the stent-first group, as measured by the modified Rankin Scale (mRS). No study evaluated the difference in time to reperfusion for the anterograde and retrograde approach and its association with clinical outcome. The patient in the illustrative case had AIS and tandem occlusion of the internal carotid and middle cerebral arteries and underwent distal revascularization using a Solitaire stent retrieval device followed by angioplasty and stent treatment of the proximal cervical carotid occlusion. The revascularization was graded as TICI 2b; the postintervention National Institutes of Health Stroke Scale (NIHSS) score was 17, and the discharge NIHSS score was 7. The admitting, postoperative, and 30-day mRS scores were 5, 1, and 1, respectively. CONCLUSIONS In stroke patients with tandem occlusions, distal to proximal revascularization represents a reasonable treatment approach and may offer the advantage of decreased time to reperfusion, which is associated with better functional outcome. Further studies are warranted to determine the best techniques in endovascular therapy to use in this subset of patients in order to improve clinical outcome.

Open Embolectomy of Large Vessel Occlusion in the Endovascular Era: Results of a 12-Year Single-Center Experience.

Mechanical endovascular embolectomy using stent retrievers has gained popularity for treatment of large vessel occlusion in acute ischemic stroke. Use of open embolectomy as a direct surgical treatment has been limited, likely owing to the technical difficulty, therapeutic time window, and time-consuming procedure. We retrospectively reviewed clinical and radiographic records of patients who underwent open embolectomy for major artery occlusion at an acute stage. Clinical features, complications, and outcome of patients were analyzed. From January 2004 to September 2016, 153 patients underwent 157 open embolectomies for major artery occlusion. Complete recanalization was achieved in 96.2% of patients. A favorable outcome was observed in 43.9%. Cerebral aneurysm along the occluded artery was observed in 11 patients with 12 aneurysms. Open embolectomy resulted in a high complete recanalization rate with an acceptable safety profile. Open embolectomy is a safe and durable method of cerebral recanalization in patients with embolic stroke and can be considered as a potential treatment if endovascular embolectomy cannot be performed. The details of the occluded arteries presented here will be useful for endovascular surgeons to prevent complications.

Comparison between enhanced susceptibility-weighted angiography and time of flight sequences in the detection of arterial occlusion in acute ischemic stroke

PurposeOptimizing the MRI protocol in acute ischemic stroke remains a challenging issue. In this field, susceptibility-weighted sequences have proved their superiority over T2*. Besides the strengthened susceptibility effect, enhanced susceptibility-weighted angiography (eSWAN) sequence provides also a time-of-flight (TOF) effect, allowing the exploration of the intracranial arterial circulation. The objective of our study was to compare eSWAN and 3D TOF, considered as the reference, in the detection of arterial occlusion in acute stroke. MethodsPatients who underwent MRI between March and July 2014 for suspected acute stroke with an acute ischemic lesion on diffusion-weighted imaging (DWI) were prospectively included in this study. eSWAN and TOF images were analyzed under double-blind conditions by a junior radiologist and a senior neuroradiologist for the detection of arterial occlusion. eSWAN images were assessed in order to estimate the inter-observer agreement. After a consensus, eSWAN and TOF data were compared to calculate inter-modality agreement. ResultsThirty-four patients were included. Inter-observer agreement was excellent (kappa: 0.96) for eSWAN detection of occlusion. After consensus, comparison between TOF and eSWAN showed substantial agreement (kappa: 0.71). eSWAN provided better detection of distal occlusions, but poorer performance for detection of siphon occlusions. ConclusionsShortest echoes eSWAN images enabled detection of arterial occlusion with substantial agreement with TOF images. The susceptibility vessel sign associated with the TOF effect improved the identification of distal occlusions. In acute stroke protocol, eSWAN may represent a valuable alternative to T2* and TOF sequences.

4D-CTA improves diagnostic certainty and accuracy in the detection of proximal intracranial anterior circulation occlusion in acute ischemic stroke.

IntroductionIn acute ischemic stroke, imaging of the cranio-cervical vessels is essential for intra-arterial treatment selection. Fast, reliable and easy accessible imaging is necessary 24 hours a day, 7 days a week. Radiologists in training and non-expert readers often perform initial reviewing. In this pilot study, the potential benefit of adding 4Dimensional-CT Angiography (4D-CTA) to the patient selection protocol for intra-arterial therapy is investigated.Materials and methodsTwenty-five datasets of prospectively recruited patients, eligible for intra-arterial treatment, were enrolled. Four radiologists-in-training consecutively reviewed CTA, CT-Perfusion and 4D-CTA (post-processed from CTP datasets) and scored: occlusion-presence and diagnostic certainty (scale 1–10). Time-to-diagnosis was registered.ResultsArterial occlusion was present in 8 patients. Accuracy improved from 88–92% after CTA and CTP assessment to 96–100% after 4D-CTA assessment (P-values >0,05). Mean diagnostic certainty improved from 7,2–8,6 to 8,8–9,3 (P-values all < 0,05). Mean time to diagnosis increased from 3, 5, 5 and 4 minutes after CTA to 9, 14, 12, and 10 minutes after 4D-CTA.Conclusion4D-CTA as an additive to regular CTA and CT-Perfusion in patients with acute ischemic stroke eligible for intra-arterial treatment shows a tendency to increase diagnostic accuracy and improves diagnostic certainty, when reviewed by radiologist in training, while only mildly prolonging time to diagnosis.

Abstract TP317: Hyperglycemia Strongly Predicts Large Ischemic Infarct Growth Despite Full Endovascular Reperfusion

Introduction: Ischemic infarct core grows at variable rates despite early reperfusion. The purpose of this study was to determine the predictors of infarct growth despite full recanalization of a large vessel occlusion in acute ischemic stroke. Method: Patients with acute ischemic stroke due to ICA or MCA occlusion who received endovascular therapy with Thrombolysis in Cerebral Infarction scale (TICI) scores of 2b or greater were subsequently selected between July 2012 and May 2016. The Alberta Stroke Program Early CT Score (ASPECT) was measured on the initial CT or MRI upon arrival and subsequently on the 24-hour scan. The infarct growth (delta d) was measured as initial ASPECT minus 24-hour ASPECT. Large and small infarct growth was defined as delta d of &gt;= to3 and &lt; 3 respectively. The relationship between the infarct growth and baseline variables of blood glucose level(BG), time of symptoms onset to recanalization time and baseline ASPECT score were assessed using statistical analysis. Results: Total of 76 patients were included. 32% had large infarct growth (25/76). The initial ASPECT score was not significantly different between the the 2 subgroups of large and small delta d (7.5 vs 6, P= 0.97). Baseline BG level was significantly higher in the group with larger infarct growth (160 vs 128, P=0.006). The baseline BG level of more than 150 was found as the threshold between the 2 subgroups (P=0.0003). No association was found between the infarct growth and history of diabetes (P= 0.7). Conclusion: Our data suggests that infarct growth occurs in relatively high percentage of ischemic stroke patients despite early full reperfusion of the large vessel occlusion. We showed that baseline blood glucose level particularly levels of higher than 150 is significantly associated with larger infarct growth. Therefore, it can be used as a strong predictive value in early recognition of this patient population.

Endovascular Treatment of Tandem Common Carotid Artery Origin and Distal Intracranial Occlusion in Acute Ischemic Stroke

Tandem occlusion resulting in acute ischemic stroke is associated with high morbidity and mortality and a poor response to thrombolytic therapy. The use of endovascular strategies for tandem stroke cases results in an improved outcome for this subgroup of patients. We present 2 cases with a pattern of tandem occlusion consisting of proximal obstruction at the origin of the common carotid artery (CCA) with concomitant intracranial occlusion treated by endovascular techniques. The 2 patients presented each with occlusion at the left CCA origin and ipsilateral intracranial vessel (left middle cerebral artery and carotid terminus, respectively). A transfemoral anterograde approach was used to deliver a balloon-mounted stent across the proximal CCA origin occlusion to gain access to the distal cerebral vasculature. Subsequently, a stent retriever assisted mechanical aspiration thrombectomy was used to revascularize the intracranial occlusion. Complete revascularization with Thrombolysis in Cerebral Infarction scores of 2b and improvement in neurologic deficits occurred in both cases. Good clinical outcome was achieved for both patients at 3-month follow-up. An anterograde transfemoral approach should be considered in cases of tandem occlusion of the proximal CCA and middle cerebral artery.

Detection of single-phase CTA occult vessel occlusions in acute ischemic stroke using CT perfusion-based wavelet-transformed angiography.

To determine the detection rate of intracranial vessel occlusions using CT perfusion-based wavelet-transformed angiography (waveletCTA) in acute ischemic stroke patients, in whom single-phase CTA (spCTA) failed to detect an occlusion. Subjects were selected from a cohort of 791 consecutive patients who underwent multiparametric CT including whole-brain CT perfusion. Inclusion criteria were (1) significant cerebral blood flow (CBF) deficit, (2) no evidence of vessel occlusion on spCTA and (3) follow-up-confirmed acute ischemic infarction. waveletCTA was independently analysed by two readers regarding presence and location of vessel occlusions. Logistic regression analysis was performed to identify predictors of waveletCTA-detected occlusions. Fifty-nine patients fulfilled the inclusion criteria. Overall, an occlusion was identified using waveletCTA in 31 (52.5%) patients with negative spCTA. Out of 47 patients with middle cerebral artery infarction, 27 occlusions (57.4%) were detected by waveletCTA, mainly located in the M2 (15) and M3 segments (8). The presence of waveletCTA-detected occlusions was associated with larger CBF deficit volumes (odds ratio (OR) = 1.335, p = 0.010) and shorter times from symptom onset (OR = 0.306, p = 0.041). waveletCTA is able to detect spCTA occult vessel occlusions in about half of acute ischemic stroke patients and may potentially identify more patients eligible for endovascular therapy. • waveletCTA is able to detect spCTA occult vessel occlusions in stroke patients. • waveletCTA-detected occlusions are associated with larger cerebral blood flow deficits. • waveletCTA has the potential to identify more patients eligible for endovascular therapy. • waveletCTA implies neither additional radiation exposure nor extra contrast agent.

Endovascular Therapy for Large Vessel Stroke in the Elderly: Hope in the New Stroke Era

Background and Purpose: Acute ischemic stroke (AIS) in the elderly encompasses approximately one-third of all AIS cases. Outcome data have been for the most part discouraging in this population. We aim to evaluate the outcomes in a large contemporary series of elderly patients treated with thrombectomy. Methods: Retrospective analysis of a single-center endovascular database for consecutive elderly (≥80 years) patients treated for anterior circulation large vessel occlusion AIS between September 2010 and April 2015. Univariate- and multivariate analyses were performed to identify the predictors of good clinical outcome (90-day modified Ranking Scale [mRS] ≤2). Receiver operating characteristic curves were used to calculate the optimal final infarct volume (FIV) threshold to predict good outcomes. Results: A total of 111 patients met our inclusion criteria (mean age 84.8 ± 4.2 years; National Institutes of Health Stroke Scale [NIHSS] score 19.1 ± 5.6; time from last-known normal to puncture, 349.6 ± 246.6 min; 33% male; 68% Alberta Stroke Program Early CT Score [ASPECTS] ≥8). The rates of successful reperfusion (modified treatment in cerebral ischemia ≥2b), symptomatic intracranial hemorrhage and 90-day mortality were 80%, 7% and 41%, respectively. The overall rate of good outcome was 29% (n = 32/111) but was 52% (n = 13/25) in patients with baseline mRS score of 0-2 who were selected based on CT perfusion and treated with stent retrievers. On multivariate analysis, only ASPECTS (OR 2.17; 95% CI 1.28-3.67.7; p = 0.004) and baseline NIHSS score (OR 0.87; 95% CI 0.77-0.97; p = 0.013) were independently associated with good outcome. A FIV ≤16 ml demonstrated the greatest accuracy for identifying good outcomes (sensitivity 75.0%, specificity 82.6%). Conclusions: Our results are encouraging demonstrating nearly one-third of elderly patients achieving full independence at 90 days. Contemporary treatment paradigms employing optimized patient selection and modern thrombectomy technology may result in even better outcomes.

Manual thromboaspiration technique as a first approach for endovascular stroke treatment: A single-center experience.

For intracranial large vessel occlusion in acute ischemic stroke (AIS), a high degree of revascularization in the minimal amount of time predicts good outcomes. Recently, different studies have shown that the direct aspiration first pass technique (ADAPT technique) for AIS obtains high recanalization rates, fast interventions and low costs when it works as first attempt. This study retrospectively describes revascularization efficacy, duration of procedure, intra and post-procedural complications, early and after 90-days clinical outcome in a group of patients who underwent ADAPT as the primary endovascular approach, eventually followed by stent retriever thrombectomy, for recanalization of large vessels in the anterior circulation. We analyzed clinical and procedural data of patients treated from April 2014 to August 2015. Recanalization was assessed according to the Thrombolysis in Cerebral Infarction score. Clinical outcome was evaluated at discharge and after 3 months (modified Rankin Scale, mRS). Overall, 71 patients (mean age of 69.7 years) were treated. Sites of occlusion were anterior circulation (including seven tandem extracranial-intracranial occlusions). In 39 patients i.v. rtPA was attempted. Recanalization of the target vessel was obtained in 87.3% of cases whereas direct aspiration alone was successful in 46/71cases (64.8%) with an average puncture-to-revascularization time of 43.1 minutes. Symptomatic intracranial hemorrhage occurred in 7.8% and embolization to new territories in 5.6%. In total, 38 patients (53.5%) had a good outcome at 90 days follow-up. In our series, the manual thromboaspiration technique has been shown as fast and safe, with good rates of vessel revascularization in 87.3% of patients and neurological outcome <3 mRS in 53.5% of patients.

Presence of the hyperintense acute reperfusion marker on MRI after mechanical thrombectomy for large vessel occlusion is associated with worse early neurological recovery

BackgroundMechanical thrombectomy has become the accepted treatment for large vessel occlusion in acute ischemic stroke. Unfortunately, a large cohort of patients do not achieve functional independence with treatment, even though...

Predicting Large Vessel Occlusion in Acute Ischemic Stroke: Less is More.

Predicting Large Vessel Occlusion in Acute Ischemic Stroke: Less is More.

Pre and intrahospital workflow for acute stroke treatment.

With the recent demonstration of the effectiveness of rapid recanalization of large vessel occlusions in acute ischemic stroke, it is important to assess the current status of pre and intrahospital workflow for acute stroke. We will review trends in the evaluation and treatment of acute stroke and offer suggestions for how best to advance the workflow for acute stroke care in the coming years. Future research is needed for: field use of clinical scores for predicting large vessel occlusions, telemedicine to facilitate prehospital triage, and pre and intrahospital processes for optimizing stroke care delivery.