scholarly journals Effects of White Matter Hyperintensities on 90-Day Functional Outcome after Large Vessel and Non-Large Vessel Stroke

2020 ◽  
Vol 49 (4) ◽  
pp. 419-426
Author(s):  
Christoph Johannes Griessenauer ◽  
David McPherson ◽  
Andrea Berger ◽  
Ping Cuiper ◽  
Nelson Sofoluke ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
White Matter ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Brain Mri ◽  
Large Vessel ◽  
Favorable Outcome ◽  
White Matter Hyperintensity ◽  
Vessel Occlusion ◽  
Brain Extraction

Introduction: White matter hyperintensity (WMH) burden is a critically important cerebrovascular phenotype related to the diagnosis and prognosis of acute ischemic stroke. The effect of WMH burden on functional outcome in large vessel occlusion (LVO) stroke has only been sparsely assessed, and direct LVO and non-LVO comparisons are currently lacking. Material and Methods: We reviewed acute ischemic stroke patients admitted between 2009 and 2017 at a large healthcare system in the USA. Patients with LVO were identified and clinical characteristics, including 90-day functional outcomes, were assessed. Clinical brain MRIs obtained at the time of the stroke underwent quantification of WMH using a fully automated algorithm. The pipeline incorporated automated brain extraction, intensity normalization, and WMH segmentation. Results: A total of 1,601 acute ischemic strokes with documented 90-day mRS were identified, including 353 (22%) with LVO. Among those strokes, WMH volume was available in 1,285 (80.3%) who had a brain MRI suitable for WMH quantification. Increasing WMH volume from 0 to 4 mL, age, female gender, a number of stroke risk factors, presence of LVO, and higher NIHSS at presentation all decreased the odds for a favorable outcome. Increasing WMH above 4 mL, however, was not associated with decreasing odds of favorable outcome. While WMH volume was associated with functional outcome in non-LVO stroke (p = 0.0009), this association between WMH and functional status was not statistically significant in the complete case multivariable model of LVO stroke (p = 0.0637). Conclusion: The burden of WMH has effects on 90-day functional outcome after LVO and non-LVO strokes. Particularly, increases from no measurable WMH to 4 mL of WMH correlate strongly with the outcome. Whether this relationship of increasing WMH to worse outcome is more pronounced in non-LVO than LVO strokes deserves additional investigation.

White Matter Hyperintensity Burden and Collateral Circulation in Large Vessel Occlusion Stroke

Stroke ◽  
2021 ◽  
Author(s):  
Imad Derraz ◽  
Mohamed Abdelrady ◽  
Nicolas Gaillard ◽  
Raed Ahmed ◽  
Federico Cagnazzo ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
White Matter ◽  
Acute Ischemic Stroke ◽  
Collateral Circulation ◽  
Large Vessel ◽  
White Matter Hyperintensity ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy

Background and Purpose: White matter hyperintensity (WMH), a marker of chronic cerebral small vessel disease, might impact the recruitment of leptomeningeal collaterals. We aimed to assess whether the WMH burden is associated with collateral circulation in patients treated by endovascular thrombectomy for anterior circulation acute ischemic stroke. Methods: Consecutive acute ischemic stroke due to anterior circulation large vessel occlusion and treated with endovascular thrombectomy from January 2015 to December 2017 were included. WMH volumes (periventricular, deep, and total) were assessed by a semiautomated volumetric analysis on fluid-attenuated inversion recovery–magnetic resonance imaging. Collateral status was graded on baseline catheter angiography using the American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grading system (good when ≥3). We investigated associations of WMH burden with collateral status. Results: A total of 302 patients were included (mean age, 69.1±19.4 years; women, 55.6%). Poor collaterals were observed in 49.3% of patients. Median total WMH volume was 3.76 cm 3 (interquartile range, 1.09–11.81 cm 3 ). The regression analyses showed no apparent relationship between WMH burden and the collateral status measured at baseline angiography (adjusted odds ratio, 0.987 [95% CI, 0.971–1.003]; P =0.12). Conclusions: WMH burden exhibits no overt association with collaterals in large vessel occlusive stroke.

Abstract WP205: Pipeline for Automated White Matter Hyperintensity Segmentation in Patients With Acute Ischemic Stroke: The MRI-GENIE Study

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Markus D Schirmer ◽  
Adrian V Dalca ◽  
Ramesh Sridharan ◽  
Anne-Katrin Giese ◽  
Joseph P Broderick ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
White Matter ◽  
Acute Ischemic Stroke ◽  
Large Scale ◽  
Current Knowledge ◽  
Principal Component ◽  
White Matter Hyperintensity ◽  
Brain Extraction ◽  
Fluid Attenuated Inversion Recovery ◽  
Good Agreement

Introduction: White matter hyperintensity volume (WMHv) is an important and highly heritable cerebrovascular phenotype; however, manual or semi-automated approaches to clinically acquired MRI analysis hinder large-scale studies in acute ischemic stroke (AIS). In this work, we develop a high-throughput, fully automated WMHv analysis pipeline for clinical fluid-attenuated inversion recovery (FLAIR) images to facilitate rapid genetic discovery in AIS. Methods: Automated WMHv extraction from multiple subjects relies on significant pre-processing of medical scans, including co-registration of the images. To reduce the effects of anisotropic voxel sizes, each FLAIR image is upsampled using bi-cubic interpolation. Brain extraction is performed using RObust Brain EXtraction (ROBEX). Images are then registered to an in-house FLAIR template using Advanced Normalization Tools (ANTs). The spatial covariation of WMH is learned through principal component analysis (PCA) of manual outlines from 100 subjects. Areas of leukoaraiosis are identified and separated from other lesions using the PCA modes. Volumes are then computed using non-interpolated slices for each subject. Standard deviation (SD) in WMHv (9 subjects; 6 raters each) is calculated as a measure of variability. Good agreement between automated and manual outlines is assessed in 358 subjects (automated WMHv within 3SD of manual WMHv). Results: As part of the MRI - Gen etics I nterface E xploration (MRI-GENIE) study, WMHv were calculated on a set of 2703 FLAIR images of patients from 12 independent AIS cohorts (sites). Results are shown in Figure 1. Comparing manual and automated WMHv shows that 88% of the automated WMHv fall within 3 SD from the manual WMHv, suggesting good agreement. Conclusion: WMHv segmentation using a fully-automated pipeline for analysis of clinical MRIs is both feasible and accurate. Ongoing analysis of the extracted WMHv is expected to advance current knowledge of risks and outcomes in AIS.

scholarly journals Workflow Intervals of Endovascular Acute Stroke Therapy During On- Versus Off-Hours

Stroke ◽  
2019 ◽  
Vol 50 (10) ◽  
pp. 2842-2850 ◽  
Author(s):  
Wouter H. Hinsenveld ◽  
Inger R. de Ridder ◽  
Robert J. van Oostenbrugge ◽  
Jan A. Vos ◽  
Adrien E. Groot ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Large Vessel ◽  
Complication Rates ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Significant Difference

Background and Purpose— Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours. Methods— We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models. Results— We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar. Conclusions— Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.

scholarly journals White matter hyperintensity burden in patients with ischemic stroke treated with thrombectomy

Neurology ◽  
2019 ◽  
Vol 93 (16) ◽  
pp. e1498-e1506 ◽  
Author(s):  
Grégoire Boulouis ◽  
Nicolas Bricout ◽  
Wagih Benhassen ◽  
Marc Ferrigno ◽  
Guillaume Turc ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
White Matter ◽  
Functional Independence ◽  
Unfavorable Outcome ◽  
Favorable Outcome ◽  
White Matter Hyperintensity ◽  
Vessel Occlusion ◽  
Good Argument ◽  
Symptomatic Intracerebral Hemorrhage ◽  
Procedural Success

IntroductionTo determine the influence of white matter hyperintensity (WMH) burden on functional outcome, rate of symptomatic intracerebral hemorrhage (sICH), and procedural success in patients with acute ischemic stroke (AIS) treated by mechanical thrombectomy (MT) with current stentriever/aspiration devices.MethodsPatients with AIS due to large vessel occlusion (LVO) from the Thrombectomie des Artères Cérébrales (THRACE) trial and prospective cohorts from 2 academic comprehensive stroke centers treated with MT were pooled and retrospectively analyzed. WMH volumes were obtained by semiautomated planimetric segmentation and tested in association with the rate of favorable outcome (90-day functional independence), substantial recanalization after MT, and sICH.ResultsA total of 496 participants were included between 2015 and 2018 (50% female, mean age 68.1 ± 15.0 years). Overall, 434 (88%) patients presented with detectable WMH (mean ± SD 4.93 ± 7.7). Patients demonstrated increasingly worse outcomes with increasing WMH volumes (odds ratio [aOR]1.05 per 1-cm3 increase for unfavorable outcome, 95% confidence interval [CI] 1.01–1.06, p = 0.014). Fifty-seven percent of patients in the first quartile of WMH volume vs 28% in the fourth quartile demonstrated favorable outcome (p < 0.001). WMH severity was not associated with sICH rate (aOR 0.99, 95% CI 0.93–1.04, p = 0.66), nor did it influence recanalization success (aOR 0.99, 95% CI 0.96–1.02, p = 0.84).ConclusionOur study provides evidence that in patients with AIS due to LVO and high burden of WMH as assessed by pretreatment MRI, the safety and efficacy profiles of MT are similar to those in patients with lower WMH burden and confirms that they are at higher risk of unfavorable outcome. Because more than a quarter of patients in the highest WMH quartile experienced favorable 3 months outcome, WMH burden may not be a good argument to deny MT.ClinicalTrials.gov IdentifierNCT01062698.

scholarly journals Dabigatran Reversal Before Intravenous Tenecteplase in Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1616-1619 ◽  
Author(s):  
James Beharry ◽  
Michael J. Waters ◽  
Roy Drew ◽  
John N. Fink ◽  
Duncan Wilson ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Scale Score ◽  
Clinical Laboratory ◽  
Intravenous Thrombolysis ◽  
Interquartile Range ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Background and Purpose— Reversal of dabigatran before intravenous thrombolysis in patients with acute ischemic stroke has been well described using alteplase but experience with intravenous tenecteplase is limited. Tenecteplase seems at least noninferior to alteplase in patients with intracranial large vessel occlusion. We report on the experience of dabigatran reversal before tenecteplase thrombolysis for acute ischemic stroke. Methods— We included consecutive patients with ischemic stroke receiving dabigatran prestroke treated with intravenous tenecteplase after receiving idarucizumab. Patients were from 2 centers in New Zealand and Australia. We reported the clinical, laboratory, and radiological characteristics and their functional outcome. Results— We identified 13 patients receiving intravenous tenecteplase after dabigatran reversal. Nine (69%) were male, median age was 79 (interquartile range, 69–85) and median baseline National Institutes of Health Stroke Scale score was 6 (interquartile range, 4–21). Atrial fibrillation was the indication for dabigatran therapy in all patients. All patients had a prolonged thrombin clotting time (median, 80 seconds [interquartile range, 57–113]). Seven patients with large vessel occlusion were referred for endovascular thrombectomy, 2 of these patients (29%) had early recanalization with tenecteplase abrogating thrombectomy. No patients had parenchymal hemorrhage or symptomatic hemorrhagic transformation. Favorable functional outcome (modified Rankin Scale score, 0–2) occurred in 8 (62%) patients. Two deaths occurred from large territory infarction. Conclusions— Our experience suggests intravenous thrombolysis with tenecteplase following dabigatran reversal using idarucizumab may be safe in selected patients with acute ischemic stroke. Further studies are required to more precisely estimate the efficacy and risk of clinically significant hemorrhage.

Abstract P317: White Matter Hyperintensity Lesion Burden Modulates Functional Outcome After Acute Ischemic Stroke

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Anna K Bonkhoff ◽  
Sungmin Hong ◽  
Markus Schirmer ◽  
Martin Bretzner ◽  
Anne-Katrin Giese ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
White Matter ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
White Matter Hyperintensity ◽  
Study Cohort ◽  
Stroke Severity ◽  
Ischemic Lesion ◽  
Long Term Outcome ◽  
Index Stroke

Introduction: As a radiographic signature of end-stage small vessel disease, white matter hyperintensity (WMH) burden impacts recovery and outcomes after acute ischemic stroke (AIS). In this study, we sought to investigate the effect of WMH volume (WMHv) on stroke severity and functional outcomes independent of the infarct size and topography. Methods: We analyzed 503 AIS patients with MRI data obtained on admission for index stroke enrolled in the multi-center MRI-GENIE study (cohort 1), followed by validation of the findings in an independent single-site study of 555 AIS patients (cohort 2). Stroke severity (NIHSS score) at index stroke and the long-term outcome (3-6 months mRS score) were modeled via Bayesian linear regression. Models included WMHv, age, sex, a 10-dimensional spatial ischemic lesion representation, acute infarct (DWI) volume, and common vascular risk factors (hypertension, diabetes mellitus, atrial fibrillation, coronary artery disease). Results: Cohorts did not differ significantly in major clinical characteristics [cohort 1: age: 65.0±14.6, 41% female, NIHSS: 5.5±5.4, mRS: 1(iqr 2); cohort 2: age: 65.0±14.8, 38% female, NIHSS: 5.0±6.0, mRS: 1(iqr 3), p >0.05 for all comparisons]. WMHv did not substantially affect AIS severity ( Fig A ); in contrast, it emerged as an independent predictor of functional outcome in both datasets ( Fig B ). Conclusions: When accounted for AIS lesion topography and stroke volume, total WMH lesion burden did not appear to modulate initial stroke severity but was associated with worse functional post-stroke outcomes. Future studies are needed to explore potential origins of these detrimental effects of pre-existing WMH burden on recovery after AIS.

scholarly journals White Matter Hyperintensity, Immediate Antihypertensive Treatment, and Functional Outcome After Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (5) ◽  
pp. 1608-1612
Author(s):  
Shiguang Zhu ◽  
Sifan Qian ◽  
Tan Xu ◽  
Hao Peng ◽  
Ruiguo Dong ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
White Matter ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Hospital Discharge ◽  
Scale Score ◽  
Antihypertensive Treatment ◽  
White Matter Hyperintensity ◽  
Risk Of Death ◽  
Increased Risk

Background and Purpose— It remains unknown that whether white matter hyperintensity (WMH) severity influences the effect of antihypertensive treatment in acute ischemic stroke. We aimed to investigate the effects of early antihypertensive treatment on death and disability among patients with acute ischemic stroke according to WMH severities. Methods— This study was a secondary analysis of the data from CATIS (China Antihypertensive Trial in Acute Ischemic Stroke). Severity of WMH was evaluated using Fazekas rating scale score among 303 participants with available magnetic resonance imaging data and was categorized into none-mild WMH (Fazekas score 0–2) and moderate-severe WMH (Fazekas score 3–6). Functional outcome was death or major disability (modified Rankin Scale score of ≥3) at 14 days or hospital discharge and within 3 months. Results— WMH severity was significantly associated with an increased risk of death or major disability. Each 1 score increase in Fazekas score was associated with an adjusted odds ratio (95% CI) of 1.25 (1.03–1.51) for 14 days or hospital discharge and 1.39 (1.12–1.72) for 3-month functional outcome. There were no significant interactions between antihypertensive treatment and WMH severity (both P >0.1) on functional outcome at 14 days or hospital discharge and within 3 months. The neutral effects of immediate antihypertensive treatment were observed both in patients with moderate-severe WMH and none-mild WMH. Conclusions— Participants with higher WMH burden had increased risk of death or major disability after acute ischemic stroke. Early antihypertensive treatment had a neutral effect on clinical outcomes among acute ischemic stroke patients with a variety of WMH severities. Registration— URL: https://www.clinicaltrials.gov ; Unique identifier: NCT01840072.

Abstract WP166: The Effectiveness of Statin Therapy After Onset of Acute Ischemic Stroke With Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Kazutaka Uchida ◽  
Shinichi Yoshimura ◽  
Nobuyuki Sakai ◽  
Hiroshi Yamagami ◽  
Takeshi Morimoto ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Statin Therapy ◽  
Functional Outcome ◽  
Randomized Clinical Trials ◽  
Large Vessel ◽  
Registry Study ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Statin Group

Background: Statin therapy was reported to be associated with lower risk of recurrence of stroke and better functional outcomes in patients with acute ischemic stroke. However, the effect of statin therapy in patients with acute large vessel occlusion (LVO) was not well scrutinized. Thus, we evaluated the effect of statin administration after the onset of stroke on functional outcome based on the large registry study of acute LVO. Methods: RESCUE-Japan Registry-2 was a physician initiated registry study enrolled consecutive patients with acute LVO who were admitted within 24 hours of onset. We compared those with and without statin after onset in terms of modified Rankin Scale (mRS) at 90 days. We estimated the common odds ratio (OR) for a shift towards better mRS adjusting for confounders. Result: Among 2420patients registered, 2399 patients were eligible. Mean age was 75.9 years and men accounted for 55%. Statin were administered in 447 patients(19%) after admission. There are more atherothrombotic cerebral infarction (statin group: 34.2% vs non-statin group: 12.1%, p <0.0001), younger age (73.4 vs 76.5, p <0.0001), and lower NIHSS on admission (14 vs 17, p <0.0001) in the statin group. The adjusted common OR of the statin group was 1.22 (95% confidence interval [CI], 1.04 - 1.37; p =0.02) compared with the non-statin group. The safety profile was similar between groups. The mortality at 90 days was 4.7 % in the statin group lower than 12.5 % in the non-statin group (p <0.0001). The adjusted OR of statin group for mortality was 0.36 (95%CI 0.21 to 0.62, p = 0.022). Conclusions: Statin administration after onset of acute LVO was significantly associated with better functional outcome and mortality within 90 days. Our findings should be attested by randomized clinical trials in patients with acute LVO in future

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