Occlusion Ischemic Stroke Research Articles

Prolonged Venous Transit on Perfusion Imaging is Associated with Longer Lengths of Stay in Acute Large Vessel Occlusions.

Prolonged venous transit (PVT+) is a marker of venous outflow; it is defined as the presence or absence of time-to-maximum ≥10 seconds timing in either the superior sagittal sinus or torcula. This novel perfusion imaging-based metric has been associated with higher odds of mortality and lower odds of functional recovery. This study aims to assess the relationship between PVT on admission perfusion imaging and length of hospital stay in large vessel occlusion strokes successfully reperfused with mechanical thrombectomy. Acute ischemic stroke patients with large vessel occlusions in the anterior circulation successfully treated with thrombectomy between 01/2017 and 09/2022 were retrospectively reviewed. The primary outcome was length of stay in the hospital due to the acute stroke event. Univariable and forward stepwise multivariable linear regressions were performed for the primary outcome. Of 109 patients meeting inclusion, median age was 71 (interquartile range [IQR] 62-80) years. Median hospital length of stay was significantly greater in PVT+ patients (9 [IQR 6-18] days) compared to PVT-patients (6 [IQR 4-12] days, p=0.03). In multivariable regression, PVT+ was significantly associated with length of stay, and PVT+ was associated with approximately two additional days of hospital stay compared to PVT-(p=0.03). In successfully reperfused large vessel occlusion strokes, PVT+ was associated with an additional two days of hospital stay on average compared to PVT-patients, when adjusting for other clinical covariables. This simple, novel imaging metric is robust in correlating with a range of short and long term clinical outcomes. VO = venous outflow; Tmax = time-to-maximum; PVT = prolonged venous transit; AIS-LVO = large vessel occlusion ischemic stroke; SSS = superior sagittal sinus; rCBF = relative cerebral blood flow; IQR = interquartile range; VIF = variance inflation factor.

Perfusion-Based Relative Cerebral Blood Volume Is Associated With Functional Dependence in Large-Vessel Occlusion Ischemic Stroke.

Pretreatment computed tomography perfusion parameter relative cerebral blood volume (rCBV) lesion volume has been shown to predict 90-day modified Rankin Scale score in small-core strokes with Alberta Stroke Program Early Computed Tomography Score ≥5, including those with medium-vessel occlusions (mid and distal M2 segment occlusions). Hence, in this study we aim to assess the performance of different rCBV lesion volume thresholds (rCBV <42%, rCBV <38%, and rCBV <34%) with 90-day modified Rankin Scale score including patients with large core (Alberta Stroke Program Early Computed Tomography Score <5) and strictly including only patients with anterior circulation large-vessel occlusion. In this retrospective evaluation of our prospectively collected database, inclusion criteria were (1) Computed tomographic angiography confirmed anterior circulation large-vessel occlusion from September 1, 2017, to October 1, 2023; and (2) diagnostic computed tomography perfusion. Student t test, Mann-Whitney U test, and χ2 test were used in the univariate data analysis. Spearman's rank correlation analysis was used to assess correlations. Outcome measure was dichotomized into good functional outcome (90-day modified Rankin Scale score, 0-2) and poor functional outcome (90-day modified Rankin Scale score, 3-6) for logistic regression and receiver operating characteristic analysis. P≤0.05 was considered significant. In total, 229 patients met our inclusion criteria. The majority of the patients (n=161) in our cohort had M1 occlusion. All the rCBV thresholds were significantly higher in patients with poor 90-day functional outcomes and were independently associated with the outcome. Spearman's rank correlation analysis revealed a slightly stronger correlation of rCBV <42% (ρ=0.27, P<0.001), as compared with rCBV <38% (ρ=0.25, P<0.001) and rCBV <34% (ρ=0.24, P<0.001) with functional outcome. Receiver operating characteristic analysis revealed that rCBV <42% (area under the curve, 0.67 [95% CI, 0.60-0.74]; P<0.001) performed marginally better than rCBV <38% (area under the curve, 0.66 [95% CI, 0.59-0.73]; P<0.001), and rCBV <34% (area under the curve, 0.65 [95% CI, 0.58-0.72]; P<0.001). All the rCBV thresholds were independently associated with poor 90-day functional outcome; however, the rCBV <42% marginally outperformed rCBV <38% and rCBV <34% lesion volumes.

Recruitment of pial collaterals and carotid occlusive disease in large-vessel occlusion ischemic stroke.

Despite the fundamental role of pial collateral vessels in limiting the progression of ischemic tissue injury in acute stroke with large vessel occlusion (LVO), in addition to the fact that collateral vessel abundance varies naturally from person to person for genetic reasons, there is limited knowledge regarding potential factors contributing to inherent interindividual variation in pial collateral supply. As it has been repeatedly hypothesized that chronic carotid occlusive disease may favor pial collateralization, we aimed to investigate the association between quantitatively assessed leptomeningeal collateral supply and pre-existing carotid stenosis in patients with acute stroke due to LVO. Patients with proximal middle cerebral artery (MCA) occlusion with or without additional internal carotid artery (ICA) occlusion were included. The degree of collateral supply was quantitatively assessed based on signal variance in T2*-weighted time series in perfusion-weighted magnetic resonance imaging (PWI). Patients were stratified into two groups according to quantitative collateral status (poor and fair to good collateral supply). The prevalence of high-grade ICA stenosis (≥70%) was evaluated in both groups. A total of 98 patients (mean age 68.8 ± 16.1 years, n = 52 (53.1%) of whom were female individuals) with MCA and/or ICA occlusion were included in the final analysis. Out of these patients, 42 had poor collateral supply, while 56 exhibited fair to good collateral supply. Additionally, 18 patients showed ipsilateral high-grade ICA stenosis. After classifying the entire cohort based on their collateral status (poor vs. fair to good collateral supply), there was no significant difference in the proportion of the patients with ipsilateral high-grade ICA stenosis between the two groups. Specifically, 6 (14.3%) patients had poor collateral supply, and 12 (21.1%) patients had fair to good collateral supply. The odds ratio (OR) was 1.58, with a 95% confidence interval (CI) of 0.490-5.685 and the p-value of 0.440. In the entire patient cohort, signal variance-based collateral supply was significantly correlated with initial stroke severity (r = -0.360, p < 0.001), baseline ischemic core volume (r = -0.362, p < 0.001), and functional outcomes (score on the modified Rankin Scale) at discharge (r = -0.367, p < 0.01). In this study, we performed a quantitative and observer-independent MRI-based collateral assessment in patients with LVO. We found no significant difference in the prevalence of pre-existing high-grade ICA stenosis between patients with fair to good collateral supply and those with poor collateral supply. The potential influence of demographic and clinical variables on pial collateral supply in patients with acute stroke warrants further exploration in future studies. MRI-based collateral supply is significantly related to initial stroke severity, ischemic core volume, and early functional outcomes.

The effectiveness of optic nerve sheath diameter in predicting large vessel occlusion in ischemic stroke patients

Aim: This study assessed the effectiveness of ultrasonography-measured optic nerve sheath diameter (ONSD) in predicting large vessel occlusion (LVO) in ischemic stroke patients.Materials and methods: This single-center, prospective observational study involved patients presenting to the emergency department within 24 hours of symptom onset with moderate to severe stroke, and healthy volunteers.Results: The study included 133 ischemic stroke patients and 63 healthy volunteers. The patient group had significantly higher right [5.8 (0.9)] and left [5.9 (0.8)] ONSD values compared to controls (right [5.7 (0.6)], left [5.7 (0.8)], p&lt;0.001 for both). LVO was present in 58.6% (n = 78) of patients. Median right ONSD was 6.1 mm (0.8) in LVO patients vs. 5.7 mm (0.65) in non-LVO patients (p=0.002). Median left ONSD was 5.9 mm (0.9) in LVO patients vs. 5.7 mm (0.7) in non-LVO patients (p=0.002). A right ONSD ≥6 mm had 51.28% sensitivity and 78.18% specificity for LVO. A left ONSD ≥5.5 mm had 83.33% sensitivity and 40% specificity for LVO.Conclusion: Elevated ONSD values measured by ultrasonography can effectively indicate LVO in stroke patients.

Insights into multilevel tissue-level collateral status using ColorViz maps from dual data sources in acute ischemic cerebrovascular diseases: A STARD-compliant retrospective study.

This study aims to explore the utility of ColorViz mapping from dual data sources for assessing arterial collateral circulation and predicting cerebral tissue-level collateral (TLC) in patients with acute ischemic cerebrovascular diseases. A retrospective study was conducted at a single center on a cohort of 79 patients diagnosed with acute ischemic cerebrovascular diseases between November 2021 and April 2022, who had undergone both multi-phase CT angiography (mCTA) and computed tomography perfusion (CTP). The quality of images and arterial collateral status depicted on ColorViz maps from dual data-sets (mCTA and CTP) were assessed using a "5-point scale" and a "10-point scale," respectively. The status of TLC was evaluated by analyzing multilevel hypoperfusion volume and the hypoperfusion intensity ratio (HIR). The Spearman correlation coefficient was employed to examine the association between arterial collateral status derived from dual data sources and TLC. Receiver operating characteristic curve analysis was used to determine the diagnostic efficacy in detecting large vessel occlusive acute ischemic stroke (LVO-AIS). The ColorViz maps derived from dual data sources facilitated comparable image quality, with over 95% of cases meeting diagnostic criteria, for the evaluation of arterial level collateral circulation. Patients with robust arterial collateral circulation, as determined by dual data sources, were more likely to exhibit favorable TLC status, as evidenced by reductions in hypoperfusion volume (Tmax > 4 seconds, Tmax > 6 seconds, Tmax > 8 seconds, and Tmax > 10 seconds, P < .05) and HIR (Tmax > 6 seconds/4 seconds, Tmax > 8 seconds/4 seconds, Tmax > 10 seconds/4 seconds, and Tmax > 8 seconds/6 seconds, P < .05). The sensitivity and specificity in detecting LVO-AIS was 60.00% and 97.73% for mCTA source maps, while 74.29% and 72.73% for CTP source maps (P > .05 based on De-Long test). In conclusion, this study indicates that ColorViz maps derived from both data sources are equally important in evaluating arterial collateral circulation and enhancing diagnostic efficiency in patients with LVO-AIS, as well as offering insights into the TLC status based on hypoperfusion volume and HIR.

Association between heart failure and cerebral collateral flow in large vessel occlusive ischemic stroke

BackgroundCerebral collateral circulation plays a crucial role in determining the extent of brain ischemia in large vessel occlusive (LVO) stroke. Heart failure (HF) is known to cause cerebral hypoperfusion, yet the relationship between HF and robustness of collateral flow has not been well described. MethodsConsecutive patients with middle cerebral and/or internal carotid LVO who underwent endovascular thrombectomy (EVT) between 2012 and 2020 were included. Single-phase head CTA prior to EVT was used to assess collateral status (poor <50 % filling; good ≥50 %). Classification of HF by left ventricular ejection fraction (LVEF) on echocardiogram was used where HF with reduced ejection fraction (HFrEF) had LVEF ≤40 %, HF with preserved EF (HFpEF) had LVEF ≥50 % with evidence of structural heart disease, and no HF had LVEF≥50 % without structural heart disease. Multivariable logistic regression analyses were performed to evaluate the association between HF and poor collaterals. ResultsWe identified 235 patients, mean age was 69 ± 15 years; initial NIHSS was 18 ± 7. Of these, 107 (45.5 %) had HF and 105 (44.7 %) had poor collaterals. Those with HF were likely to have poor collaterals compared to those without HF (56.1 % vs 35.2 %, P = 0.001). There was a dose-dependent relationship between EF and poor collaterals: adjusted odds of poor collaterals were 1.63 and 2.45 in HFpEF and HFrEF, compared to those without HF (trend P = .018). ConclusionPatients with HFrEF are more likely to have poor cerebral collaterals. Further study is needed to explore the pathomechanisms. Optimization of HF may improve cerebral collaterals and enhance EVT outcomes.

Plasma Brain-Derived Tau in Prognosis of Large Vessel Occlusion Ischemic Stroke.

Large vessel occlusion acute ischemic stroke prognosis improved following the 2015 endovascular therapy (EVT) trials. Blood-based biomarkers may improve outcome prediction. We aimed to assess plasma brain-derived tau (BD-Tau) performance in predicting post-EVT large vessel occlusion acute ischemic stroke outcomes. We included 2 temporally independent prospective cohorts of anterior circulation in patients with large vessel occlusion acute ischemic stroke who successfully recanalized post-EVT. We measured plasma BD-Tau, GFAP (glial-fibrillary-acidic-protein), NfL (neurofilament-light-chain), and total-Tau upon admission, immediately, 24 hours, and 72 hours post-EVT. Twenty-four-hour neuroimaging and 90-day functional outcomes were independently assessed using the Alberta Stroke Program Early Computed Tomography Score (good outcome: >7 or unchanged) and the modified Rankin Scale (favorable outcome <3 or unchanged), respectively. Based on the first cohort (derivation), we built a multivariable logistic regression model to predict a 90-day functional outcome. Model results were evaluated using the second cohort (evaluation). In the derivation cohort (n=78, mean age=72.9 years, 50% women), 62% of patients had a good 24-hour neuroimaging outcome, and 45% had a favorable 90-day functional outcome. GFAP admission-to-EVT rate-of-change was the best predictor for early neuroimaging outcome but not for 90-day functional outcome. At admission, BD-Tau levels presented the highest discriminative performance for 90-day functional outcomes (area under the curve, 0.76 [95% CI, 0.65-0.87]; P<0.001). The model incorporating age, admission BD-Tau, and 24-hour Alberta Stroke Program Early Computed Tomography Score achieved excellent discrimination of 90-day functional outcome (area under the curve, 0.89 [95% CI, 0.82-0.97]; P<0.001). The score's predictive performance was maintained in the evaluation cohort (n=66; area under the curve, 0.82 [95% CI, 0.71-0.92]; P<0.001). Admission plasma BD-Tau accurately predicted 90-day functional outcomes in patients with large vessel occlusion acute ischemic stroke after successful EVT. The proposed model may predict functional outcomes using objective measures, minimizing human-related biases and serving as a simplified prognostic tool for AIS.

Relationship Between Baseline Infarct and Clinical Outcome in Pediatric Large‐Vessel Occlusion Ischemic Stroke

Background In adults with large‐vessel occlusion stroke, the extent of the baseline infarct measured using the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) predicts outcome and is used during patient selection for mechanical thrombectomy. The relationship between ASPECTS and clinical outcome is unknown in pediatric large‐vessel occlusion stroke. Methods Secondary analysis of a retrospective multicenter case–control study assessing mechanical thrombectomy versus medical management alone for pediatric large‐vessel occlusion stroke across 5 centers in Australia and Canada from 2011 to 2022. ASPECTS was measured on baseline computed tomography or magnetic resonance imaging–diffusion‐weighted imaging while blinded to clinical outcome and treatment status. The relationship between ASPECTS and pediatric modified Rankin scale scores at 3 months following stroke was assessed using ordinal logistic regression. Results In total, n = 24 thrombectomy patients (F = 10, mean age, 11.3 years [SD, 4.36]) and n = 24 control patients (F = 10, mean age, 10.2 years [SD, 4.32) were included. Mean ASPECTS was 6.3 (SD, 2.37) in the thrombectomy group and 6.1 (SD, 2.64) in the control group. In patients undergoing thrombectomy, baseline ASPECTS significantly correlated with pediatric modified Rankin scale scores at 3 months (odds ratio, 1.58 [95% CI, 1.10–2.27]; P = 0.013). In control patients, there was no significant correlation (odds ratio, 1.17 [95% CI, 0.87–1.55]; P = 0.298). Six of 7 thrombectomy patients with a large baseline infarct (ASPECTS &lt;6) had a pediatric modified Rankin scale score of 0 to 2 at final follow‐up. Conclusion Baseline ASPECTS was significantly associated with clinical outcome in pediatric patients with large‐vessel occlusion stroke who received mechanical thrombectomy. Thrombectomy patients with low ASPECTS demonstrated favorable long‐term outcomes, suggesting ASPECTS alone should not be used to exclude pediatric patients from receiving thrombectomy.

Functional Outcome and Hemorrhage Rates After Bridging Therapy With Tenecteplase or Alteplase in Patients With Large Ischemic Core.

IV tenecteplase is an alternative to alteplase before mechanical thrombectomy (MT) in patients with large-vessel occlusion (LVO) ischemic stroke. Little data are available on its use in patients with large ischemic core. We aimed to compare the efficacy and safety of both thrombolytics in this population. We conducted a retrospective analysis of patients with anterior circulation LVO strokes and diffusion-weighed imaging Alberta Stroke Program Early CT Score (DWI-ASPECTS) ≤5 treated with tenecteplase or alteplase before MT from the TETRIS (tenecteplase) and ETIS (alteplase) French multicenter registries. Primary outcome was reduced disability at 3 months (ordinal analysis of the modified Rankin scale [mRS]). Safety outcomes were 3-month mortality, parenchymal hematoma (PH), and symptomatic intracranial hemorrhage (sICH). We used propensity score overlap weighting to reduce baseline differences between treatment groups. We analyzed 647 patients (tenecteplase: n = 194; alteplase: n = 453; inclusion period 2015-2022). Median (interquartile range) age was 71 (57-81) years, with NIH Stroke Scale score 19 (16-22), DWI-ASPECTS 4 (3-5), and last seen well-to-IV thrombolysis and puncture times 165 minutes (130-226) and 260 minutes (203-349), respectively. After MT, the successful reperfusion rate was 83.1%. After propensity score overlap weighting, all baseline variables were well balanced between both treatment groups. Compared with patients treated with alteplase, patients treated with tenecteplase had better 3-month mRS (common odds ratio [OR] for reduced disability: 1.37, 1.01-1.87, p = 0.046) and lower 3-month mortality (OR 0.52, 0.33-0.81, p < 0.01). There were no significant differences between thrombolytics for PH (OR 0.84, 0.55-1.30, p = 0.44) and sICH incidence (OR 0.70, 0.42-1.18, p = 0.18). Our data are encouraging regarding the efficacy and reassuring regarding the safety of tenecteplase compared with that of alteplase in bridging therapy for patients with LVO strokes and a large ischemic core in routine clinical care. These results support its consideration as an alternative to alteplase in bridging therapy for patients with large ischemic cores. NCT03776877 (ETIS registry) and NCT05534360 (TETRIS registry). This study provides Class III evidence that patients with anterior circulation LVO stroke and DWI-ASPECTS ≤5 treated with tenecteplase vs alteplase before MT experienced better functional outcomes and lower mortality at 3 months.

Identifying gut microbiota with high specificity for ischemic stroke with large vessel occlusion

Gut microbiota can regulate the metabolic and immunological aspects of ischemic stroke and modulate the treatment effects. The present study aimed to identify specific changes in gut microbiota in patients with large vessel occlusion (LVO) ischemic stroke and assess the potential association between gut microbiota and clinical features of ischemic stroke. A total of 63 CSVD patients, 64 cerebral small vessel disease (CSVD) patients, and 36 matching normal controls (NCs) were included in this study. The fecal samples were collected for all participants and analyzed for gut microbiota using 16S rRNA gene sequencing technology. The abundances of five gut microbiota, including genera Bifidobacterium, Butyricimonas, Blautia, and Dorea and species Bifidobacterium_longum, showed significant changes with high specificity in the LVO patients as compared to the NCs and CSVD patients. In LVO patients, the genera Bifidobacterium and Blautia and species Bifidobacterium_longum were significantly correlated with the National Institutes of Health Stroke Scale (NIHSS) scores at the admission and discharge of the patients. Serum triglyceride levels could significantly affect the association of the abundance of genus Bifidobacterium and species Bifidobacterium_longum with the NIHSS scores at admission and modified Rankin Scale (mRS) at discharge in LVO patients. The identification of five gut microbiota with high specificity were identified in the early stage of LVO stroke, which contributed to performed an effective clinical management for LVO ischemic stroke.

Hypoperfusion Intensity Ratio Is Associated with Early Neurologic Deficit Severity and Deterioration after Mechanical Thrombectomy in Large-Vessel Occlusion Ischemic Stroke.

The hypoperfusion intensity ratio is a surrogate marker for collateral status and a predictor of infarct growth, malignant cerebral edema, and hemorrhagic transformation. Its utility to predict a poor NIHSS score and early neurologic deterioration after mechanical thrombectomy for large vessel (LVO) versus distal and medium vessel occlusions (DMVO) has not been investigated. The objective of this study was to determine whether the higher hypoperfusion intensity ratio is associated with a worse NIHSS score at 24 hours post-mechanical thrombectomy and early neurologic deterioration in LVO versus DMVO acute ischemic stroke. This was a retrospective study of 231 patients with acute ischemic stroke with LVO or DMVO amenable for mechanical thrombectomy and available CTP for hypoperfusion intensity ratio assessment pre-mechanical thrombectomy. Clinical and imaging characteristics were abstracted from the medical records. The primary outcome was the NIHSS score at 24 hours post-mechanical thrombectomy. The secondary outcome was early neurologic deterioration, defined as a >4-point increase in the NIHSS score between the initial assessment and 24 hours post-mechanical thrombectomy. All analyses were first conducted in the entire cohort and then separately for the LVO versus DMVO groups. The optimal hypoperfusion intensity ratio threshold to detect early neurologic deterioration was 0.54. A hypoperfusion intensity ratio ≥ 0.54 was more frequently present in LVO versus DMVO (n = 37 [77.1%] versus n = 11 [22.9%]; P < .001). On multivariable linear regression, the hypoperfusion intensity ratio ≥ 0.54 was independently associated with a worse NIHSS score at 24 hours post-mechanical thrombectomy in the entire cohort (β = 0.163; P = .002) and the LVO group (β = 0.210; P = .005), but not in the DMVO group. The early neurologic deterioration occurred in 26 (11.3%) subjects. On multivariable logistic regression, there was no association of the hypoperfusion intensity ratio ≥ 0.54 with early neurologic deterioration in the entire cohort. However, when analyzed separately, a hypoperfusion intensity ratio ≥ 0.54 significantly increased the odds of early neurologic deterioration in subjects with LVO (OR = 5.263; 95% CI, 1.170-23.674; P = .030) but not in the DMVO group. The hypoperfusion intensity ratio ≥ 0.54 was independently associated with a worse 24-hour post-mechanical thrombectomy NIHSS score and early neurologic deterioration in LVO, but not in DMVO acute ischemic stroke. Pending confirmation in future, prospective studies assessing the hypoperfusion intensity ratio may help identify patients at risk of secondary decline to improve peri-thrombectomy care and clinical decision-making.

Prospective Validation of Glial Fibrillary Acidic Protein, d ‐Dimer, and Clinical Scales for Acute Large‐Vessel Occlusion Ischemic Stroke Detection

Background Large‐vessel occlusion (LVO) ischemic stroke is responsible for significant morbidity and mortality. We have previously described a novel tool for acute LVO detection that combines blood‐based biomarkers (glial fibrillary acidic protein and d ‐dimer) with stroke severity scales to achieve high accuracy. Accordingly, the present study sought to prospectively validate cutoff values that we had previously established for biomarkers and scales. Methods The TIME (Testing for Identification Markers of Stroke) trial was designed as a prospective observational diagnostic accuracy study. All ambulance‐identified stroke code activations &lt;18 hours from symptom onset were recruited at Brandon Regional Hospital (Brandon, FL) between May 2021 and August 2022. Previously determined cutoff concentrations of plasma glial fibrillary acidic protein (213 pg/mL) and d ‐dimer (600 ng/mL) were used in combination with prehospital stroke scales to detect LVO. We compared rates of LVO detection against a reference standard using computed tomography/magnetic resonance angiography. Results A total of 382 patients with suspected stroke were recruited. The final cohort was composed of 323 patients with suspected stroke with the following distribution: LVO ischemic stroke (n = 29, 9%), non‐LVO ischemic stroke (n = 48, 15%), hemorrhagic stroke (n = 13, 4%), transient ischemic attack (n = 12, 3.9%), and stroke mimics (n = 220, 68.1%). Combining blood‐based biomarkers (glial fibrillary acidic protein and d ‐dimer) with the scale field assessment stroke triage for emergency destination yielded the best performance for LVO detection, with specificity of 94% and sensitivity of 71%. Performance was found to be higher in a subanalysis focusing on patients presenting &lt;6 hours from symptom onset, with 93% specificity and 81% sensitivity. Critically, application of the biomarker and stroke scale algorithms ruled out all patients with hemorrhage. Conclusion The present work prospectively validated the potential utility of previously defined glial fibrillary acidic protein and d ‐dimer cutoff levels (ie, 213 pg/mL and 600 ng/mL, respectively), demonstrating their value for discrimination of LVO stroke from differential diagnoses during code stroke workups. (ClinicalTrials.gov number, NCT04292600.)

Hypoperfusion Index Ratio is Associated with Early Neurological Deficit Severity and Decline after Mechanical Thrombectomy in Large Vessel Occlusion Ischemic Stroke (P2-5.004)

Hypoperfusion Index Ratio is Associated with Early Neurological Deficit Severity and Decline after Mechanical Thrombectomy in Large Vessel Occlusion Ischemic Stroke (P2-5.004)

Risk and benefit of reinitiating antiplatelet therapy after spontaneous intracerebral hemorrhage: a systematic review and meta-analysis.

This study aimed to assess the risks and benefits of reinitiating antiplatelet therapy after spontaneous intracerebral hemorrhage (ICH) through a systematic review and meta-analysis. The reinitiation of antiplatelet therapy is commonly used to reduce major vascular events in patients with occlusive vascular diseases, but its use in ICH patients may increase the risk of bleeding. A comprehensive search was conducted on databases including MEDLINE, Embase, Cochrane Library, clinicaltrials.gov, and the International Standard Randomized Controlled Trial Number Register (ISRCTN). Randomized controlled trials and cohort studies that investigated the use of reinitiation of antiplatelet therapy after hemorrhagic stroke were included. Data on ICH recurrence, major bleeding events, major occlusive cerebrovascular events, ischemic stroke, and all-cause mortality were extracted and analyzed using R software. The study included a total of 10 studies with 6,340 participants. The control group consisted of 2,964 patients who did not receive antiplatelet therapy, while the study group included 1,285 patients who received antiplatelet therapy without restrictions on the specific drug type. The meta-analysis showed that antiplatelet therapy significantly reduced the risk of ICH recurrence (RR=0.72, 95% CI: 0.59, 0.87), had no significant impact on the risk of severe bleeding events (RR=0.93, 95% CI: 0.80, 1.08), significantly lowered the risk of major occlusive cerebrovascular events (RR=0.59, 95% CI: 0.46, 0.77), had no significant effect on the risk of ischemic stroke (RR=0.77, 95% CI: 0.53, 1.12), and did not significantly influence the risk of all-cause mortality (RR=0.75, 95% CI: 0.45, 1.15). Based on the findings, reinitiating antiplatelet therapy after spontaneous ICH appears to be generally safe. However, the benefits in terms of reducing the risk of all-cause mortality are not evident and require confirmation through large-scale, long-term, prospective, randomized controlled trials.

Low Cerebral Blood Volume Index, Thrombectomy, and Prior Stroke Are Independently Associated With Hemorrhagic Transformation in Medium‐Vessel Occlusion Ischemic Stroke

Background Hemorrhagic transformation (HT) is a major complication in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy. However, HT in patients with AIS due to medium‐vessel occlusions has still not been well researched. In large‐vessel occlusions, collateral status is an important determinant of postprocedural HT, and the cerebral blood volume (CBV) index is a reliable surrogate of collateral status. The aim of our study is to identify an optimal CBV index threshold associated with HT in patients with AIS due to medium‐vessel occlusion and evaluate additional parameters that are independently associated with HT in this group. Methods This retrospective analysis of our prospectively collected database from 2 comprehensive stroke centers consisted of patients presenting with AIS due to medium‐vessel occlusion from 2019 to 2023. The primary outcome was the presence of HT on follow‐up imaging. Optimal CBV index cutoff for HT was derived from a univariate logistic regression analysis. Multivariable logistic regression analysis for HT was derived from the dichotomized CBV index and other covariates. The receiver operator characteristic curve yielded area under the curve. Statistical significance was P ≤ $ \le $ 0.05. Results Of 111 patients (median age, 70 years; 43.2% women) included, 26 (23.4%) patients had HT. The optimal CBV index cutoff was 0.7. From multivariable regression analysis, significant variables included prior stroke (adjusted odds ratio [aOR], 7.18 [95% CI, 1.60–32.16]; P = 0.01), endovascular thrombectomy attempt (aOR, 7.86 [95% CI, 1.78–34.68]; P = 0.01), and CBV index ( ≤ $ \le $ 0.7; aOR, 4.23 [95% CI, 1.02–17.59]; P = 0.04). The area under the curve was 0.82 (95% CI, 0.69–0.91). Conclusion A CBV index ≤ $ \le $ 0.7 was independently associated with HT in patients with AIS due to medium‐vessel occlusion. Endovascular thrombectomy attempt and prior stroke history were also independently associated with HT in this population.

Clinical uncertainty in large vessel occlusion ischemic stroke: does automated perfusion imaging make a difference? An intra-rater and inter-rater agreement study

BackgroundLimited research exists regarding the impact of neuroimaging on endovascular thrombectomy (EVT) decisions for late-window cases of large vessel occlusion (LVO) stroke.ObjectiveT0 assess whether perfusion CT imaging: (1) alters the...

Brain imaging prior to thrombectomy in the late window of large vessel occlusion ischemic stroke: a systematic review and meta-analysis.

Optimal imaging modalities to select patients for endovascular thrombectomy (EVT) in the late window of acute ischemic stroke due to large vessel occlusions (AIS-LVO) are not known. We conducted a systematic review comparing outcomes of patients selected by non-contrast computed tomography (NCCT)/CT angiography (CTA) vs. those selected by CT perfusion (CTP) or magnetic resonance imaging (MRI) for EVT in these patients. We searched PUBMED, EMBASE, and the Cochrane Library from January 1, 2000, to July 15, 2023, to identify studies comparing outcomes of patients selected for EVT by NCCT/CTA vs. CTP or MRI in the late time window for AIS-LVO. Primary outcome was independence (mRS 0-2) at 90days or discharge. Secondary outcomes were symptomatic intracranial hemorrhage (sICH) and mortality. We pooled data across studies based on an inverse variance method. Six cohort studies with 4208 patients were included. Pooled results showed no significant difference in the rate of independence at 90days or discharge (RR 0.96, 95% CI 0.88-1.03) and sICH (RR 1.26, 0.85-1.86) between patients selected by NCCT/CTA vs. CTP or MRI for EVT in the late window of AIS-LVO. However, patients selected by NCCT/CTA vs. CTP or MRI for EVT were associated with a higher risk of mortality (RR 1.21, 1.06-1.39). For AIS-LVO in the late window, patients selected by NCCT/CTA compared with those selected by CTP or MRI for EVT might have a comparable rate of functional independence and sICH. Baseline NCCT/CTA may triage AIS-LVO in the late window.

Abstract WMP93: Door-to-Thrombolysis Time Between Primary Stroke Centers and Comprehensive Stroke Centers: Is There an Added Benefit?

Introduction: Comprehensive Stroke Centers are skilled, highly trained facilities that provide advanced care to an array of stroke patients. If stroke patients are not able to reach a Comprehensive Stroke Center, Primary Stroke Centers provide convenient and rapid care to patients presenting with acute ischemic stroke. Ideally, these Primary Centers save time to intervention. Whether there are differences in time to intervention, and resultant patient outcomes, between such centers has not been thoroughly studied. To this end, we examined door-to-needle and door-to-stroke alert time between one Comprehensive Stroke Center and three Primary Stroke Centers in Northwest Ohio. Hypothesis: Primary Stroke Centers will have longer time to intervention (i.e., door-to-needle times) than that of Comprehensive Stroke Centers. Methods: From 2018-2023, we examined door-to-needle and door-to-stroke alert times in patients presenting to the ProMedica Health System with ischemic stroke in a retrospective chart review. All patients presented with Large Vessel Occlusion (LVO) ischemic stroke. Results: 293 patients and 255 patients presented to either the Primary Centers or the Comprehensive Stroke Center, respectively. Door-to-needle time was significantly longer in patients presenting to the Primary Centers (Median: 59.00 minutes), compared to the Comprehensive Stroke Centers (Median: 39.50) (Mann Whitney U-Test: p &lt;0.0001). However, door-to-stroke alert was not different between the two centers (Primary, Median: 2; Comprehensive, Median: 1, Mann Whitney U-Test: p = 0.099). Conclusions: We report a longer latency to needle in Primary Stroke Centers compared to Comprehensive Stroke Centers, with no change in door-to-stroke alert time. It is forthcoming whether this difference impacts patient outcome measures. Such findings suggest that stopping at Primary Stroke Centers may not provide either a time- or outcome-benefit in lieu of immediate arrival to a Comprehensive Stroke Center.

Abstract WP153: Factors Affecting Length of ICU Stay After Endovascular Thrombectomy for Acute Large Vessel Ischemic Stroke

Introduction: The advent of endovascular thrombectomy (EVT) for acute large vessel occlusion (LVO) ischemic stroke has reduced the overall ICU length of stay (LoS), especially for patients undergoing successful reperfusion. Prolonged ICU LoS is reported to be associated with worse clinical outcomes, but factors associated with prolonged LoS after MT are not established. Methods: A retrospective analysis of 499 patients undergoing EVT at a single large comprehensive stroke center from January 2015 to May 2020 was performed. Demographics, procedure variables, ICU LoS, ICU complications, and modified Rankin scale at discharge were collected. Multiple regression was used to identify independent variables affecting the ICU LoS. Additional analysis using t-test assuming unequal variances was performed for select variables. Results: The median age was 72 [61-82], 254 (51%) male &amp; median NIHSS was 16 [10-20]. The average door-to-puncture time was 104 ±28 mins and the average procedure time 43.9 ±28.7. General anesthesia (GA) was administered in 257 (51%) patients. Successful reperfusion (TICI 2c-3) was achieved in 334 (67%) patients. Median ICU LoS was 3 days [1-5]. Patients with mRS 0-2 at discharge (33%) had shorter ICU LoS (2.8 vs 5.7, P&lt;0.001). ASPECTS &lt; 7 (6.9 vs 4.6, P=0.03), use of GA (6.2 vs 3.3 days, P&lt;0.001) and ICU complications such as pulmonary embolism (PE) and pneumonia (10 vs 4 days; p &lt;0.001) significantly increased the ICU LoS. Successful reperfusion significantly reduced ICU LoS (4.2 vs 5.8 days, p=0.015). After adjusting for age, sex, baseline NIHSS and ASPECTS, both the procedure time (b= 0.03, P=0.02) and final TICI score (b= -0.76, P=0.001) were independently associated with prolonged ICU LoS (R2=0.1, F=4, P&lt;0.001). Conclusion: Pre-procedural factors such as poor ASPECTS (&lt; 7), procedural factors such as the use of GA, prolonged procedure time, and TICI 0-2b reperfusion, and ICU complications such as pneumonia and PE are associated with prolonged ICU LoS.

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&lt;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 &gt;= 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.