Successful Endovascular Reperfusion Research Articles

Abstract 81: Time From Imaging to Endovascular Reperfusion Predicts Outcome in Acute Stroke

Objective: This study aims to describe the relationship between CT perfusion-to-reperfusion time and the probability of functional independence in a cohort of patients undergoing endovascular therapy for acute ischemic stroke. Methods: We included data from the CT Perfusion to predict Response in Ischemic Stroke Project (CRISP) in which all patients underwent a baseline CT perfusion (CTP) scan prior to endovascular therapy. Patients were included if they had a mismatch on their baseline CT perfusion scan and achieved successful endovascular reperfusion. Patients with mismatch were categorized into ‘target mismatch’ and ‘malignant mismatch’ profiles, according to the volume of their Tmax>10s lesion volume (target mismatch <100 mL; malignant mismatch >100 mL). We investigated the impact of CTP-to-reperfusion times on probability of achieving functional independence (mRS 0-2) at day 90 and radiographic outcomes at day 5. Results: Of 156 included patients, 108 (59%) had the target mismatch profile, and 48 (26%) had the malignant mismatch profile. In patients with the target mismatch profile, CTP-to-reperfusion time showed no association with functional independence (p=0.84), whereas in patients with malignant mismatch profile, CTP-to-reperfusion time was strongly associated with lower probability of functional independence (OR=0.08, p=0.003). Compared to patients with target mismatch, those with the malignant mismatch profile had significantly more infarct growth (90 [49-166] vs. 43 [18-81] mL, p=0.006) and larger final infarct volumes (110 [61-155 vs. 48 [21-99] mL, p=0.001]). Conclusion: Patients with the target mismatch and malignant mismatch profile respond differently to time delays between baseline imaging and endovascular reperfusion; those with the malignant profile demonstrate a more rapid decline in favorable clinical outcomes and have greater infarct growth.

急性期脳主幹動脈閉塞に対する血管内治療後の転帰良好例における早期症候改善についての検討

【背景】血管内治療で再開通を得て，3カ月後転帰良好であった急性期脳主幹動脈閉塞例において，早期症候改善の意義や関連因子は明らかでない．【方法】2012年4月～2016年3月の急性期脳主幹動脈閉塞血管内治療施行連続173例のうち有効再開通が得られ3カ月後転帰良好（modified Rankin Scale ［mRS］スコア0–2）に至った症例を対象に，early dramatic recovery（EDR，24時間後のNIHSSスコア10以上改善または0–3）の臨床転帰への影響，および関連因子を後方視的に検討した．【結果】53例（年齢70.3±12.1歳，女性17例，術前NIHSSスコア中央値15 ［四分位範囲11–21］）を対象とした．EDR群（45例）は非EDR群に比し3カ月後mRSが低く（中央値1［0–2］ vs. 2［1–2］, p=0.03），白血球数（7826.7±2827.7 vs. 10137.5±3112.2/μl，p=0.03），血清BUN/Cre比（18.1±6.0 vs. 24.7±8.1，p=0.02）が低値であった．多変量解析では血清BUN/Cre比がEDRに関連した（オッズ比 0.81，95％信頼区間 0.65–0.94）．【結論】血管内治療で有効再開通が得られ3カ月後転帰良好であった脳主幹動脈閉塞例では，血清BUN/Cre比低値がEDRに関連し，EDR例は非EDR例に比べて3カ月後mRSスコアが低かった．

Abstract WMP11: Arterial Occlusive Lesion Location Does Not Impact Functional Outcome in Patients with Endovascular Reperfusion

Introduction: The relationship between clinical outcome and arterial occlusive lesion (AOL) location in patients after endovascular therapy is not fully determined. We aimed to investigate if the location of the arterial occlusive lesion (AOL) is an independent predictor of good functional outcome. Hypothesis: AOL location impacts clinical outcome with distal lesions having higher rates of good functional outcome (GFO) in reperfused patients. Methods: Using data from the CTP to predict Response to recanalization in Ischemic Stroke Project (CRISP), a multi-center, NIH-sponsored prospective cohort study, we analyzed the effect of AOL location on clinical outcome. Patients were included if they had documented reperfusion on early follow-up MR or CT perfusion imaging (>50% reduction in Tmax>6s lesion volume) or on angiography (TICI 2b or 3). Good functional outcome was defined as mRS score 0-2 at day 90. AOL location was categorized as proximal ICA, distal ICA, MCA-M1, or MCA-M2. Fully automated perfusion software (RAPID) was used to calculate CTP infarct core volume (rCBF<30%) and critically hypoperfused tissue volume (Tmax>6s). We assessed whether age, NIHSS score, infarct core, critically hypoperfused tissue, and AOL are associated with GFO using univariate and multivariate analyses. Results: The analysis included 167 of 201 patients (proximal ICA=21, distal ICA=32, M1=99, M2=15). Median NIHSS score (IQR) for groups were respectively: 18(14-22), 18(15-23), 17(11-20), 15( 13-19). Mean core volumes (mL) (IQR) were: 24.2(1.1-22.9), 13.0(0.0-17.7), 16.5(0.0-26.2), 10.6(1.1-13.0). Significant independent predictors of GFO were age (OR 0.82 for every 5 year increment, 95% CI 0.72-0.94), NIHSS score (OR 0.86, 95% CI 0.79-0.93), and core volume (OR 0.78 for every 10 mL increase, 95% CI 0.62-0.94), whereas AOL location (p=0.8-0.9) and the volume of critically hypoperfused tissue (p=0.5) were not significant in univariate and multivariate analyses. Conclusion: Baseline symptom severity, infarct core volume, and age drive functional outcomes in stroke patients with successful endovascular reperfusion. These variables, but not AOL location and volume of critically hypoperfused tissue, should be used for prognostication in the acute setting.

Younger Stroke Patients With Large Pretreatment Diffusion-Weighted Imaging Lesions May Benefit From Endovascular Treatment.

Lesion volume on diffusion-weighted magnetic resonance imaging (DWI) before acute stroke therapy is a predictor of outcome. Therefore, patients with large volumes are often excluded from therapy. The aim of this study was to analyze the impact of endovascular treatment in patients with large DWI lesion volumes (>70 mL). Three hundred seventy-two patients with middle cerebral or internal carotid artery occlusions examined with magnetic resonance imaging before treatment since 2004 were included. Baseline data and 3 months outcome were recorded prospectively. DWI lesion volumes were measured semiautomatically. One hundred five patients had lesions >70 mL. Overall, the volume of DWI lesions was an independent predictor of unfavorable outcome, survival, and symptomatic intracerebral hemorrhage (P<0.001 each). In patients with DWI lesions >70 mL, 11 of 31 (35.5%) reached favorable outcome (modified Rankin scale score, 0-2) after thrombolysis in cerebral infarction 2b-3 reperfusion in contrast to 3 of 35 (8.6%) after thrombolysis in cerebral infarction 0-2a reperfusion (P=0.014). Reperfusion success, patient age, and DWI lesion volume were independent predictors of outcome in patients with DWI lesions >70 mL. Thirteen of 66 (19.7%) patients with lesions >70 mL had symptomatic intracerebral hemorrhage with a trend for reduced risk with avoidance of thrombolytic agents. There was a growing risk for poor outcome and symptomatic intracerebral hemorrhage with increasing pretreatment DWI lesion volumes. Nevertheless, favorable outcome was achieved in every third patient with DWI lesions >70 mL after successful endovascular reperfusion, whereas after poor or failed reperfusion, outcome was favorable in only every 12th patient. Therefore, endovascular treatment might be considered in patients with large DWI lesions, especially in younger patients.

Impact of time-to-reperfusion on outcome in patients with poor collaterals.

The relationship between reperfusion and clinical outcome is time-dependent, and the effect of reperfusion on outcome can vary on the basis of the extent of collateral flow. We aimed to identify the impact of time-to-reperfusion on outcome relative to baseline angiographic collateral grade in patients successfully treated with endovascular revascularization for acute large-vessel anterior circulation stroke. Two hundred seven patients were selected for analysis from our prospectively maintained registry. Inclusion criteria were M1 MCA ± ICA occlusions, onset-to-puncture time within 8 hours, and successful endovascular reperfusion. Baseline angiographic collateral grades were independently evaluated and dichotomized into poor (0-1) versus good (2-4). Multivariable analyses were performed to identify the effect of collateral-flow adequacy on favorable outcome on the basis of onset-to-reperfusion time and puncture-to-reperfusion time. In the poor collateral group, the odds of favorable outcome significantly dropped for patients with onset-to-reperfusion time of >300 minutes or puncture-to-reperfusion time of >60 minutes (onset-to-puncture time: ≤300, 59% versus >300, 32%; OR, 0.24; P = .011; puncture-to-reperfusion time: ≤60, 73% versus >60, 32%; OR, 0.21, P = .011), whereas the probability of favorable outcome in the good collateral group was not significantly influenced by onset-to-reperfusion time or puncture-to-reperfusion time. In the subgroup lesion-volume growth analysis by using DWI, the effect of puncture-to-reperfusion time of >60 minutes was significantly greater compared with the effect of puncture-to-reperfusion time of <60 minutes in the poor collateral group (β = 41.6 cm(3), P = .001). Time-to-reperfusion including onset-to-reperfusion time and puncture-to-reperfusion time in patients with poor collaterals is an important limiting factor for favorable outcome in a time-dependent fashion. Future trials may benefit from a noninvasive imaging technique to detect poor collaterals along with a strategy for rapid reperfusion.

Overcoming the evening/weekend effects on time delays and outcomes of endovascular stroke therapy: the Calgary Stroke Program experience

BackgroundStentrievers have resulted in faster recanalization times in patients with acute ischemic stroke. Nonetheless, when strokes occur during evenings and weekends, delays are introduced in achieving this goal. We assessed...