Proportion Of Good Outcome Research Articles

Abstract W P37: Laterality of the Posterior Cerebral Artery is Associated With a Smaller Volume of Brain Tissue at Risk in Patients With Acute Anterior Circulation Arterial Occlusion

Background: Laterality of the posterior cerebral artery (LPCA) in acute stroke has been related with a better leptomeningeal collateral circulation and with improved functional outcome at 6 months in patients treated with IV tPA. We aim to study the association between LPCA and the amount of brain tissue at risk of infarction in patients with anterior circulation arterial occlusion. Methods: From our prospective database of ischemic stroke we selected patients with anterior circulation arterial occlusion who underwent multimodal MRI < 12h of symptom onset. We considered LPCA when the following criteria were accomplished: a) ipsilateral PCA to the occlusion site was extended in 1 or more segments compared to the contralateral PCA and b) ipsilateral P4 segment was visible on axial TOF images. Two independent readers blinded to clinical data retrospectively assessed the presence of LPCA (k=0.65). We analyzed the association between LPCA and the volume of ischemic penumbra at baseline (Tmax>6s) and the final infarct volume (CT 24h). Good outcome was defined as mRS ≤ 2 at 90 days. Results: Seventy-two patients were included in the study (mean age 67y, 45% male). LPCA was present in 39 (54.1%). There were no differences between groups with or without LPCA, except a lower baseline NIHSS in the LPCA group (15 vs 19; p=0.003). Proportion of patients treated with reperfusion therapies was similar between groups. Patients with LPCA had a smaller lesion in Tmax>6s (54 vs 79cc; p=0.02), smaller final infarct volume (47 vs 111cc; p=0.013), and higher proportion of good outcome (52.8% vs 27.3%; p=0.03). In a multivariate analysis, LPCA was independently associated with smaller lesion volume on Tmax>6s (B -18, IC95% [-36,-0.3]), smaller final infarct volume (B -64.8, IC95% [-100,-29]) and better clinical outcome (OR 4.66, IC95% [1.04,20.8]). Conclusion: LPCA sign in patients with anterior circulation arterial occlusion is associated with smaller volume of brain tissue at risk resulting in smaller infarct volume and better clinical outcome. These findings suggest favorable leptomeningeal collaterals.

Abstract 72: Refining The Pre-treatment Noncontrast CT ASPECTS Threshold For IAT Selection: Pooled Analysis Of The Penumbra Pivotal Study And PICS Registry

Background: Previous studies have demonstrated that the Alberta Stroke Program Early CT Score (ASPECTS) on pre-treatment noncontrast CT (NCCT) can be used to identify patients who will benefit from intra-arterial therapy (IAT). Specifically, an ASPECTS threshold of 7 has been identified as clinically important. We sought to test this threshold and further characterize the clinical impact of pre-treatment ASPECTS (pre-ASPECTS) in a large IAT cohort. Materials and methods: We identified anterior circulation acute ischemic stroke patients treated with the Penumbra Stroke System in the Pivotal Study and the Penumbra Imaging Collaborative Study (PICS). Inclusion criteria for this analysis were evaluable pre-treatment NCCT and available 90-day modified Rankin Scale (mRS) score. Expert readers graded ischemic change on NCCT using ASPECTS and blinded to all clinical information except stroke side. Results: Of 221 patients who fulfilled study criteria, the mean age was 66.0±15.1 years, and median NIHSS score was 16 (IQR 12-21). The cohort was 50.9% (112/220) female. There were 111 (50.2%) right-sided strokes. The target vessel occlusion involved the ICA in 21.9% (48/219), MCA in 77.6% (170/219) and ACA in 0.5% (1/219). The median ASPECTS was 7 (IQR 6-9). TIMI 2-3 reperfusion was achieved in 83% (181/218). Good outcome (mRS 0-2) was achieved in 77 (34.8%) patients at 90 days. Adjusting for age, NIHSS and reperfusion, pre-treatment ASPECTS was an independent predictor of good outcome (O.R. 1.47; 95%C.I.:1.23 to 1.76). Pre-ASPECTS >7 predicted good outcome with a relative risk of 1.80 (95%C.I.:1.23 to 2.64). The proportion of good outcomes was exceedingly low among pre-ASPECTS 0-4 (2.8% [1/36]; Figure ). When trichotomizing pre-ASPECTS at 0-4 (n=36), 5-7 (n=76) and 8-10 (n=109), the median 90-day mRS scores were 6 (IQR 4-6), 3.5 (IQR 2-6) and 3 (IQR 1-4), respectively (p<0.0001). In pairwise comparison, the only significant differences were between pre-ASPECTS 0-4 and the other groups. While there was no effect of reperfusion on outcome among pre-ASPECTS 0-4, TIMI 2-3 reperfusion (p=0.04) and earlier timing of reperfusion (none vs. <300 minutes vs. ≥300 minutes; p=0.03) were associated with better outcomes among pre-ASPECTS 5-10. Conclusions: Pre-treatment NCCT ASPECTS is a critical determinant of outcome following IAT. Pre-ASPECTS 0-4 identifies a population of patients who are highly likely to have dismal outcomes and do not benefit from endovascular reperfusion.

The impact of endovascular management on the outcome of aneurysmal subarachnoid hemorrhage in the elderly in Eastern Finland

The International Subarachnoid Aneurysm Trial (ISAT) concluded that "there is currently no reason to doubt that the reduction of dependent survival or death after endovascular coiling seen in all patients in the ISAT cohort should not be valid in the elderly". We feel that this generalization requires further investigation to assess its validity. We studied the impact of treatment era and independent risk factors for outcome in 179 consecutive elderly (> or =70 years) aneurysmal subarachnoid hemorrhage (aSAH) patients admitted to Kuopio University Hospital either between 1983 and 1992 (Era I, n = 56), prior to the introduction of endovascular management, or between 1995 and 2004 (Era II, n = 123) when the endovascular treatment was established at our institute. Altogether 150 patients underwent occlusive aneurysm treatment, 47 clipping in the Era I as against 49 clipping, 49 endovascular therapy, and five combination therapy in the Era II. The 12-month survival (n = 179) did not improve from the Era I to the Era II. The proportion of good outcome (GOS IV-V) after occlusive therapy (n = 150) was equal in the Era I and Era II (n = 27/47; 57% vs. n = 56/103; 54%). In multivariate logistic regression analysis, independent predictors of poor outcome were age, poor grade (Hunt&Hess IV-V), hydrocephalus, hypertension, and intraventricular hemorrhage, but not the mode of occlusive therapy (microsurgical vs. endovascular) Clinical severity of the SAH was the most significant predictor of outcome. Integration of coil treatment in clinical practice has not improved the overall outcome of aSAH in the elderly at our institute.

Long-Term Prognosis of Patients with Large Subcortical Infarctions

Aim: We assessed the long-term prognosis of patients with large subcortical infarctions (LSCI). Methods: We defined LSCI as lesions ≥15 mm confined to deep penetrating arteries without a cardioembolic or atherothrombotic source. Patients with acute ischemic strokes were consecutively registered and followed for 751 ± 441 days. The clinical characteristics and long-term prognoses of patients with LSCI were compared to those of patients with lacunar (LACI), atherothrombotic (ATI) and cardioembolic infarctions (CEI). Results: At discharge from the hospital, the proportion of good outcomes (modified Rankin Scale ≤2) for patients with LSCI (52.1%) was similar to that for ATIs (47.2%), but worse than that for LACIs (73.2%). After a 3-year follow-up period, the mortality rates from LSCI, LACIs, ATIs and CEIs were 8.4, 8.2, 22.3 and 41.1%, respectively; the recurrence rates were 9.3, 14.1, 16.6 and 23.8%, respectively. Conclusions: The short-term prognosis of functional outcomes for LSCI was worse than that for LACIs, but similar to acute-phase ATI outcomes. The long-term prognosis after a LSCI is good, and recurrence tends to be lower than for LACIs.

Comparison of Mechanical Embolectomy and Intraarterial Thrombolysis in Acute Ischemic Stroke within the MCA: MERCI and Multi MERCI compared to PROACT II

Intraarterial thrombolysis and mechanical embolectomy have been studied for endovascular treatment of stroke. The MERCI and Multi MERCI trials of mechanical embolectomy with or without adjuvant intraarterial thrombolysis demonstrated effective recanalization, but with a higher mortality compared with control patients in the PROACT II trial of intraarterial thrombolysis. Differences in trial design may account for this mortality difference. We identified patients in the MERCI and Multi MERCI trials who would have been eligible for PROACT II. Rates of good outcome (mRS < or =2) and mortality at 90 days were compared, adjusting for differences in baseline NIHSS score and age. Sixty-eight patients enrolled in MERCI and 81 enrolled in Multi MERCI were eligible for PROACT II. In both unadjusted and adjusted analyses, PROACT II-eligible embolectomy patients showed a trend toward better clinical outcomes compared to the PROACT II control arm (adjusted, MERCI 35.4% [p = ns], Multi MERCI 42.8% [p = 0.048], PROACT II control, 25.4%). In both unadjusted and adjusted analyses, mortality rates did not significantly differ between embolectomy patients and PROACT II control patients (adjusted analysis, MERCI 29.1%, Multi MERCI 18.0%, PROACT II control, 27.1%). Compared with the PROACT II treatment group, embolectomy groups showed similar rates of good outcome and mortality. Differences in mortality and proportion of good outcome between the MERCI/Multi MERCI trials and the PROACT II trial are explained by differences in study design and baseline characteristics of patients. Mechanical embolectomy and IA thrombolysis may each be reasonable strategies for acute stroke; a randomized trial is necessary to confirm these results.