scholarly journals Time Matters

Stroke ◽  
2020 ◽  
Vol 51 (6) ◽  
pp. 1766-1771 ◽  
Author(s):  
Manuel Requena ◽  
Marta Olivé ◽  
Álvaro García-Tornel ◽  
Noelia Rodríguez-Villatoro ◽  
Matías Deck ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Endovascular Treatment ◽  
Functional Outcome ◽  
Scale Score ◽  
Odds Ratio ◽  
Hemorrhagic Transformation ◽  
National Institutes Of Health ◽  
Retrospective Case ◽  
Good Functional Outcome ◽  
Angiography Suite

Background and Purpose— Direct transfer to angiography-suite (DTAS) protocol is a promising measure to improve onset to recanalization time in patients who undergo endovascular treatment. The magnitude of the improvement of good outcome rates in function of time depends of several factors. We aim to analyze the benefit of DTAS according to time from symptom onset. Methods— Retrospective case-control study of 174 consecutive DTAS cases matched with 175 patients initially transferred to computed tomography (directly transferred to computed tomography) from February 2016 to June 2019. To obtain comparable groups on admission, cases and controls were matched by occlusion location, age (±2 years), baseline National Institutes of Health Stroke Scale score (±2 points), and time from symptoms onset to hospital arrival (±30 minutes). We analyzed the rate of good functional outcome at 3 months (modified Rankin Scale score, 0–2) and safety variables stratified in less or more than 3 hours from onset to arrive. Results— There were no significant differences regarding age, sex, or baseline National Institutes of Health Stroke Scale score. Median door-to-groin time was shorter in the DTAS patients (16 [3–21] minutes versus 70 [41.5–98.5]; P <0.01). DTAS patients presented lower National Institutes of Health Stroke Scale score at 24 hours (9 [3.5–17] versus 14 [5–19]; P =0.01) and a lower rate of symptomatic hemorrhagic transformation (4.6% versus 10.9%, P <0.03). At 90 days, DTAS patients had a higher rate of good functional outcome (43% versus 29%; odds ratio, 1.81 [95% CI, 1.14–2.87]; P =0.01). Better outcome in DTAS was observed in patients admitted in the 0 to 3 hours form onset window (n=156, odds ratio 2.63 [95% CI, 1.31–5.28]; P <0.01), but not in patients admitted in the 3 to 6 hours window (n=193, odds ratio, 1.37 [95% CI, 0.72–2.60]; P =0.2). Conclusions— DTAS seems a feasible and safe strategy to improve functional outcome in patients who undergo endovascular treatment mainly within 3 hours from symptoms onset.

Abstract 146: Time Matters: Adjusted Analysis of the Influence of Direct Transfer to Angio-Suite Protocol in Functional Outcome

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Manuel Requena ◽  
Marta Olivé-Gadea ◽  
Álvaro García-Tornel ◽  
Noelia Rodríguez-Villatoro ◽  
Jesús Juega ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Functional Outcome ◽  
Time Windows ◽  
Hemorrhagic Transformation ◽  
Direct Transfer ◽  
Retrospective Case ◽  
Hospital Arrival ◽  
Nihss Score ◽  
Good Functional Outcome ◽  
Safe Strategy

Direct transfer to angio suite (DTAS) protocol is a promising measure to improve onset to recanalization time in patients who undergo endovascular treatment. The association of different time windows with prognosis in this population is influenced by several factors. We aim to analyze the influence of DTAS in clinical and functional outcome depending on time from symptom onset to treatment. Methods: Retrospective case-control study of 174 consecutive DTAS cases matched with 175 patients initially transferred to CT (DTCT) from February 2016 to April 2019. To obtain comparable groups on admission, cases and controls were matched by occlusion location, age (±2 years), baseline NIHSS score (±2 points) and time from symptoms onset to hospital arrival (±30 minutes). We analyzed the rate of good functional outcome at 3 months (mRS 0-2) and safety variables stratified in less or more than 3 hours from onset to arrive. Results: There were no significant differences regarding age, gender or baseline NIHSS score (table 1). Median door-to-groin time was shorter in the DTAS patients (16 (13-21) minutes Vs 70 (41.5-98.5); p<0.01). DTAS patients presented lower NIHSS score at 24 hours 9 (3.5-17) Vs 14 (5-19); p=0.01) and a lower rate of symptomatic hemorrhagic transformation (4.6% versus 10.9%, p<0.03). At 90 days, DTAS patients had a higher rate of good functional outcome (43% versus 29%; OR 1.81, 95% CI, 1.14-2.87; p=0.01). In multivariate analysis adjusted by confounding factors, better outcome in DTAS was observed in patients admitted in the 0-3 hours form onset window (n=156, OR 2.63, 95%CI: 1.31-5.28; p<0.01), but not in patients admitted in the 3-6 hours window (n=193, OR 1.37 955CI:0.72-2.60, p=0.2). Conclusion: DTAS seems a feasible and safe strategy to improve functional outcome in patients who undergo endovascular treatment mainly within 3 hours from symptoms onset.

scholarly journals Tenecteplase Versus Alteplase Between 3 and 4.5 Hours in Low National Institutes of Health Stroke Scale

Stroke ◽  
2019 ◽  
Vol 50 (2) ◽  
pp. 498-500 ◽  
Author(s):  
Ole Morten Rønning ◽  
Nicola Logallo ◽  
Bente Thommessen ◽  
Håkon Tobro ◽  
Vojtech Novotny ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Functional Outcome ◽  
Scale Score ◽  
Odds Ratio ◽  
National Institutes Of Health ◽  
Modified Rankin Scale ◽  
Unique Identifier ◽  
Clinical Trial Registration ◽  
Intention To Treat ◽  
Good Functional Outcome

Background and Purpose— Thrombolysis with alteplase has beneficial effect on outcome and is safe within 4.5 hours. The present study compares the efficacy and safety of tenecteplase and alteplase in patients treated 3 to 4.5 hours after ischemic stroke. Methods— The data are from a prespecified substudy of patients included in The NOR-TEST (Norwegian Tenecteplase Stroke Trial), a randomized control trial comparing tenecteplase with alteplase. Results— The median admission National Institutes of Health Stroke Scale for this study population was 3 (interquartile range, 2–6). In the intention-to-treat analysis, 57% of patients that received tenecteplase and 53% of patients that received alteplase reached good functional outcome (modified Rankin Scale score of 0–1) at 3 months (odds ratio, 1.19; 95% CI, 0.68–2.10). The rates of intracranial hemorrhage in the first 48 hours were 5.7% in the tenecteplase group and 6.7% in the alteplase group (odds ratio, 0.84; 95% CI, 0.26–2.70). At 3 months, mortality was 5.7% and 4.5%, respectively. After excluding stroke mimics and patients with modified Rankin Scale score of >1 before stroke, the proportion of patients with good functional outcome was 61% in the tenecteplase group and 57% in the alteplase group (odds ratio, 1.24; 95% CI, 0.65–2.37). Conclusions— Tenecteplase is at least as effective as alteplase to achieve a good clinical outcome in patients with mild stroke treated between 3 and 4.5 hours after ischemic stroke. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT01949948.

scholarly journals Mechanical Thrombectomy in Basilar Artery Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (7) ◽  
pp. 2045-2050 ◽  
Author(s):  
Hyo Sung Kwak ◽  
Jung Soo Park
Keyword(s):  
Computed Tomography ◽  
Endovascular Treatment ◽  
Scale Score ◽  
Basilar Artery ◽  
Odds Ratio ◽  
Mechanical Thrombectomy ◽  
Artery Occlusion ◽  
Posterior Circulation ◽  
National Institutes Of Health ◽  
Basilar Artery Occlusion

Background and Purpose: Basilar artery occlusion (BAO) is associated with a high risk of disability and mortality. The objective of this study was to investigate prognostic factors in patients with acute basilar artery occlusion treated with mechanical thrombectomy, focusing on collateral status and recanalization time from symptom onset. Methods: Eligible patients from January 2012 to October 2019 who underwent endovascular treatment due to acute BAO were reviewed. The baseline posterior circulation collateral status was assessed with the basilar artery on computed tomography angiography score and posterior circulation collateral score. Good outcomes were defined as a modified Rankin Scale score of ≤2 at 3 months and successful recanalization as Thrombolysis in Cerebral Infarction grades 2b, 3. The associations between baseline and clinical parameters and favorable outcomes were evaluated with logistic regression. Results: Our sample included a total of 81 eligible patients (49 males, mean age 70.3 years) with a median baseline and discharge National Institutes of Health Stroke Scale score of 12. Patients with good outcomes showed a lower baseline National Institutes of Health Stroke Scale score, a greater proportion of distal BAO, and a higher basilar artery on computed tomography angiography and posterior circulation collateral score ( P <0.001). According to subgroup analysis of patients within and over 6 or 12 hours, the time from symptom onset to recanalization was not correlated with good outcomes. Multivariable logistic analysis showed baseline National Institutes of Health Stroke Scale <15 (odds ratio, 8.49 [95% CI, 2.01–35.82]; P =0.004), posterior circulation collateral score ≥6 (odds ratio, 3.79 [95% CI, 1.05–13.66]; P =0.042), and distal BAO (odds ratio, 3.67 [95% CI, 1.10–12.26]; P =0.035) were independent predictors of good outcomes. Conclusions: This study suggested that good collateral circulation and distal BAO are independent predictors of clinical outcome after endovascular treatment in patients with acute BAO. In particular, patients with good initial collateral status and distal BAO may consider endovascular treatment even if the treatment is started beyond the standard time limits.

scholarly journals Endovascular Treatment Effect Diminishes With Increasing Thrombus Perviousness

Stroke ◽  
2021 ◽  
Author(s):  
Manon Kappelhof ◽  
Manon L. Tolhuisen ◽  
Kilian M. Treurniet ◽  
Bruna G. Dutra ◽  
Heitor Alves ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Infarct Volume ◽  
Treatment Allocation ◽  
Common Odds Ratio

Background and Purpose: Thrombus perviousness estimates residual flow along a thrombus in acute ischemic stroke, based on radiological images, and may influence the benefit of endovascular treatment for acute ischemic stroke. We aimed to investigate potential endovascular treatment (EVT) effect modification by thrombus perviousness. Methods: We included 443 patients with thin-slice imaging available, out of 1766 patients from the pooled HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials) data set of 7 randomized trials on EVT in the early window (most within 8 hours). Control arm patients (n=233) received intravenous alteplase if eligible (212/233; 91%). Intervention arm patients (n=210) received additional EVT (prior alteplase in 178/210; 85%). Perviousness was quantified by thrombus attenuation increase on admission computed tomography angiography compared with noncontrast computed tomography. Multivariable regression analyses were performed including multiplicative interaction terms between thrombus attenuation increase and treatment allocation. In case of significant interaction, subgroup analyses by treatment arm were performed. Our primary outcome was 90-day functional outcome (modified Rankin Scale score), resulting in an adjusted common odds ratio for a one-step shift towards improved outcome. Secondary outcomes were mortality, successful reperfusion (extended Thrombolysis in Cerebral Infarction score, 2B–3), and follow-up infarct volume (in mL). Results: Increased perviousness was associated with improved functional outcome. After adding a multiplicative term of thrombus attenuation increase and treatment allocation, model fit improved significantly ( P =0.03), indicating interaction between perviousness and EVT benefit. Control arm patients showed significantly better outcomes with increased perviousness (adjusted common odds ratio, 1.2 [95% CI, 1.1–1.3]). In the EVT arm, no significant association was found (adjusted common odds ratio, 1.0 [95% CI, 0.9–1.1]), and perviousness was not significantly associated with successful reperfusion. Follow-up infarct volume (12% [95% CI, 7.0–17] per 5 Hounsfield units) and chance of mortality (adjusted odds ratio, 0.83 [95% CI, 0.70–0.97]) decreased with higher thrombus attenuation increase in the overall population, without significant treatment interaction. Conclusions: Our study suggests that the benefit of best medical care including alteplase, compared with additional EVT, increases in patients with more pervious thrombi.

Radiographic Characteristics of Mild Ischemic Stroke Patients With Visible Intracranial Occlusion: The INTERRSeCT Study

Stroke ◽  
2021 ◽  
Author(s):  
H. Lee Lau ◽  
Hannah Gardener ◽  
Shelagh B. Coutts ◽  
Vasu Saini ◽  
Thalia S. Field ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Scale Score ◽  
Cerebral Artery ◽  
Odds Ratio ◽  
Arterial Occlusion ◽  
National Institutes Of Health ◽  
Collateral Flow ◽  
Residual Flow ◽  
Intravenous Alteplase ◽  
Multicenter Prospective Study

Background and Purpose: Early neurological deterioration occurs in one-third of mild strokes primarily due to the presence of a relevant intracranial occlusion. We studied vascular occlusive patterns, thrombus characteristics, and recanalization rates in these patients. Methods: Among patients enrolled in INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography), a multicenter prospective study of acute ischemic strokes with a visible intracranial occlusion, we compared characteristics of mild (National Institutes of Health Stroke Scale score, ≤5) to moderate/severe strokes. Results: Among 575 patients, 12.9% had a National Institutes of Health Stroke Scale score ≤5 (median age, 70.5 [63–79]; 58% male; median National Institutes of Health Stroke Scale score, 4 [2–4]). Demographics and vascular risk factors were similar between the two groups. As compared with those with a National Institutes of Health Stroke Scale score >5, mild patients had longer symptom onset to assessment times (onset to computed tomography [240 versus 167 minutes] and computed tomography angiography [246 versus 172 minutes]), more distal occlusions (M3, anterior cerebral artery and posterior cerebral artery; 22% versus 6%), higher clot burden score (median, 9 [6–9] versus 6 [4–9]), similar favorable thrombus permeability (residual flow grades I–II, 21% versus 19%), higher collateral flow (9.1 versus 7.6), and lower intravenous alteplase treatment rates (55% versus 85%). Mild patients were more likely to recanalize (revised arterial occlusion scale score 2b/3, 45%; 49% with alteplase) compared with moderate/severe strokes (26%; 29% with alteplase). In an adjusted model for sex, alteplase, residual flow, and time between the two vessel imagings, intravenous alteplase use (odds ratio, 3.80 [95% CI, 1.11–13.00]) and residual flow grade (odds ratio, 8.70 [95% CI, 1.26–60.13]) were associated with successful recanalization among mild patients. Conclusions: Mild strokes with visible intracranial occlusions have different vascular occlusive patterns but similar thrombus permeability compared with moderate/severe strokes. Higher thrombus permeability and alteplase use were associated with successful recanalization, although the majority do not recanalize. Randomized controlled trials are needed to assess the efficacy of new thrombolytics and endovascular therapy in this population.

Thrombectomy With and Without Computed Tomography Perfusion Imaging in the Early Time Window: A Pooled Analysis of Patient-Level Data

Stroke ◽  
2021 ◽  
Author(s):  
Ashutosh P. Jadhav ◽  
Mayank Goyal ◽  
Johanna Ospel ◽  
Bruce C. Campbell ◽  
Charles B.L.M. Majoie ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Time Window ◽  
Early Time ◽  
Computed Tomography Perfusion ◽  
Patient Level Data ◽  
Patient Level ◽  
Good Functional Outcome ◽  
Level Data

Background and Purpose: The optimal imaging paradigm for endovascular thrombectomy (EVT) patient selection in early time window (0–6 hours) treated acute ischemic stroke patients remains uncertain. We aimed to compare post-EVT outcomes between patients who underwent prerandomization basic (noncontrast computed tomography [CT], CT angiography only) versus additional advanced imaging (computed tomography perfusion [CTP] imaging) and to determine the association of performance of prerandomization CTP imaging with clinical outcomes. Methods: The HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) pooled patient-level data from randomized controlled trials comparing EVT with usual care for acute ischemic stroke due to anterior circulation large vessel occlusion. Good functional outcome, defined as modified Rankin Scale score 0 to 2 at 90 days, was compared between randomized patients with and without CTP baseline imaging. Univariable and multivariable binary logistic regression analysis was performed to determine the association of baseline CTP imaging and good functional outcome. Results: We analyzed 1348 patients 610 (45.3%) of whom underwent CTP prerandomization. The benefit of EVT compared with best medical management was maintained irrespective of the baseline imaging paradigm (90-day modified Rankin Scale score 0–2 in EVT versus control patients: with CTP: 46.0% (137/298) versus 28.9% (88/305), without CTP: 44.1% (162/367) versus 27.3% (100/366). Performance of CTP baseline imaging compared with baseline noncontrast CT and CT angiography only yielded similar rates of good outcome (odds ratio, 1.05 [95% CI, 0.82–1.33], adjusted odds ratio, 1.04, [95% CI, 0.80–1.35]). Conclusions: Rates of good functional outcome were similar among patients in whom CTP was or was not performed, and EVT treatment effect in the 0- to 6-hour time window was similar in patients with and without baseline CTP imaging.

scholarly journals High Admission Glucose Is Associated With Poor Outcome After Endovascular Treatment for Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (11) ◽  
pp. 3215-3223
Author(s):  
Leon A. Rinkel ◽  
T. Truc My Nguyen ◽  
Valeria Guglielmi ◽  
Adrien E. Groot ◽  
Laura Posthuma ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Functional Outcome ◽  
Scale Score ◽  
Intracranial Hemorrhage ◽  
Odds Ratio ◽  
Modified Rankin Scale ◽  
Poor Outcome ◽  
Increased Risk ◽  
Symptomatic Intracranial Hemorrhage ◽  
Admission Glucose

Background and Purpose: High-serum glucose on admission is a predictor of poor outcome after stroke. We assessed the association between glucose concentrations and clinical outcomes in patients who underwent endovascular treatment. Methods: From the MR CLEAN Registry, we selected consecutive adult patients with a large vessel occlusion of the anterior circulation who underwent endovascular treatment and for whom admission glucose levels were available. We assessed the association between admission glucose and the modified Rankin Scale score at 90 days, symptomatic intracranial hemorrhage and successful reperfusion rates. Hyperglycemia was defined as admission glucose ≥7.8 mmol/L. We evaluated the association between glucose and modified Rankin Scale using multivariable ordinal logistic regression and assessed whether successful reperfusion (extended Thrombolysis in Cerebral Infarction 2b-3) modified this association. Results: Of 3637 patients in the MR CLEAN Registry, 2908 were included. Median admission glucose concentration was 6.8 mmol/L (interquartile range, 5.9–8.1) and 882 patients (30%) had hyperglycemia. Hyperglycemia on admission was associated with a shift toward worse functional outcome (median modified Rankin Scale score 4 versus 3; adjusted common odds ratio, 1.69 [95% CI, 1.44–1.99]), increased mortality (40% versus 23%; adjusted odds ratio, 1.95 [95% CI, 1.60–2.38]), and an increased risk of symptomatic intracranial hemorrhage (9% versus 5%; adjusted odds ratio, 1.94 [95% CI, 1.41–2.66]) compared with nonhyperglycemic patients. The association between admission glucose levels and poor outcome (modified Rankin Scale score 3–6) was J -shaped. Hyperglycemia was not associated with the rate of successful reperfusion nor did successful reperfusion modify the association between glucose and functional outcome. Conclusions: Increased admission glucose is associated with poor functional outcome and an increased risk of symptomatic intracranial hemorrhage after endovascular treatment.

Intracranial Thrombus Extent Predicts Clinical Outcome, Final Infarct Size and Hemorrhagic Transformation in Ischemic Stroke: The Clot Burden Score

2008 ◽  
Vol 3 (4) ◽  
pp. 230-236 ◽  
Author(s):  
Volker Puetz ◽  
Imanuel Dzialowski ◽  
Michael D. Hill ◽  
Suresh Subramaniam ◽  
P.N. Sylaja ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Carotid Artery ◽  
Functional Outcome ◽  
Scale Score ◽  
Computed Tomography Angiography ◽  
Odds Ratio ◽  
Internal Carotid ◽  
Final Infarct Size ◽  
Clot Burden

Background In ischemic stroke, functional outcomes vary depending on site of intracranial occlusion. We tested the prognostic value of a semiquantitative computed tomography angiography-based clot burden score. Methods Clot burden score allots major anterior circulation arteries 10 points for presence of contrast opacification on computed tomography angiography. Two points each are subtracted for thrombus preventing contrast opacification in the proximal M1, distal M1 or supraclinoid internal carotid artery and one point each for M2 branches, A1 and infraclinoid internal carotid artery. We retrospectively studied patients with disabling neurological deficits (National Institute of Health Stroke Scale score ≥ 5) and computed tomography angiography within 24-hours from symptom onset. We analyzed percentages independent functional outcome (modified Rankin Scale score ≤ 2), final infarct Alberta Stroke Program Early Computed Tomography Score and parenchymal hematoma rates across categorized clot burden score groups and performed multivariable analysis. Results We identified 263 patients (median age 73-years, National Institute of Health Stroke Scale score 10, onset-to-computed tomography angiography time 165 min). Clot burden score < 10 was associated with reduced odds of independent functional outcome (odds ratio 0.09 for clot burden score ≤5; odds ratio 0.22 for clot burden score 6–7; odds ratio 0.48 for clot burden score 8–9; all versus clot burden score 10; P <0.02 for all). Lower clot burden scores were associated with lower follow-up Alberta Stroke Program Early CT Scores ( P <0.001) and higher parenchymal hematoma rates ( P = 0.008). Inter-rater reliability for clot burden score was 0.87 (lower 95% confidence interval 0.71) and intra-rater reliability 0.96 (lower 95% confidence interval 0.92). Conclusion The quantification of intracranial thrombus extent with the clot burden score predicts functional outcome, final infarct size and parenchymal hematoma risk acutely. The score needs external validation and could be useful for patient stratification in stroke trials.

scholarly journals Computed Tomography Perfusion After Thrombectomy

Stroke ◽  
2020 ◽  
Vol 51 (6) ◽  
pp. 1736-1742
Author(s):  
Marta Rubiera ◽  
Alvaro Garcia-Tornel ◽  
Marta Olivé-Gadea ◽  
Daniel Campos ◽  
Manuel Requena ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Endovascular Treatment ◽  
Scale Score ◽  
Interquartile Range ◽  
National Institutes Of Health ◽  
Favorable Outcome ◽  
Modified Rankin Scale ◽  
Computed Tomography Perfusion ◽  
Median Tmax ◽  
Delayed Recovery

Background and Purpose— Despite recanalization, almost 50% of patients undergoing endovascular treatment (EVT) experience poor outcome. We aim to evaluate the value of computed tomography perfusion as immediate outcome predictor postendovascular treatment. Methods— Consecutive patients receiving endovascular treatment who achieved recanalization (modified Thrombolysis in Cerebral Ischemia [mTICI] 2a-3) underwent computed tomography perfusion within 30 minutes from recanalization (CTPpost). Hypoperfusion was defined as the Tmax>6 second volume; hyperperfusion as visually increased cerebral blood flow/cerebral blood volume with reduced Tmax compared with unaffected hemisphere. Dramatic clinical recovery (DCR) was defined as 24-hour National Institutes of Health Stroke Scale score ≤2 or ≥8 points drop. Delayed recovery was defined as no-DCR with favorable outcome (modified Rankin Scale score 0–2) at 3 months. Results— We included 151 patients: median National Institutes of Health Stroke Scale score 16 (interquartile range, 10–21), median admission ASPECTS 9 (interquartile range, 8–10). Final recanalization was the following: mTICI2a 11 (7.3%), mTICI2b 46 (30.5%), and mTICI3 94 (62.3%). On CTPpost, 80 (52.9%) patients showed hypoperfusion (median Tmax>6 seconds: 4 cc [0–25]) and 32 (21.2%) hyperperfusion. There was an association between final TICI and CTPpost hypoperfusion(median Tmax>6: 91 [56–117], 15 [0–37.5], and 0 [0–7] cc, for mTICI 2a, 2b, and 3, respectively, P <0.01). Smaller hypoperfusion volumes on CTPpost were observed in patients with DCR (0 cc [0–13] versus non-DCR 8 cc [0–56]; P <0.01) or favorable outcome (modified Rankin Scale score 0–2: 0 cc [0–13] versus 7 [0–56] cc; P <0.01). No associations were detected with hyperperfusion pattern. An hypoperfusion volume <3.5 cc emerged as independent predictor of DCR (OR, 4.1 [95% CI, 2.0–8.3]; P <0.01) and 3 months favorable outcome (OR, 3.5 [95% CI, 1.6–7.8]; P <0.01). Conclusions— Hypoperfusion on CTPpost constitutes an immediate accurate surrogate marker of success after endovascular treatment and identifies those patients with delayed recovery and favorable outcome.

scholarly journals Thrombus Migration Paradox in Patients With Acute Ischemic Stroke

Stroke ◽  
2019 ◽  
Vol 50 (11) ◽  
pp. 3156-3163 ◽  
Author(s):  
Heitor C. Alves ◽  
Kilian M. Treurniet ◽  
Ivo G.H. Jansen ◽  
Albert J. Yoo ◽  
Bruna G. Dutra ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Digital Subtraction ◽  
Common Odds Ratio ◽  
Initial Target

Background and Purpose— The location of the thrombus as observed on first digital subtraction angiography during endovascular treatment may differ from the initial observation on initial noninvasive imaging. We studied the incidence of thrombus dynamics, its impact on patient outcomes, and its association with intravenous thrombolytics. Methods— We included patients from the MR CLEAN registry (Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke) with an initial target occlusion on computed tomography angiography located in the intracranial internal carotid artery, M1, or M2. The conventional angiography target occlusion was defined during endovascular treatment. Thrombus dynamics were classified as growth, stability, migration, and resolution. The primary outcome was functional outcome at 90 days (modified Rankin Scale). The secondary outcomes were successful and complete reperfusion (extended treatment in cerebral infarction scores of 2b-3 and 3, respectively). Results— The analysis included 1349 patients. Thrombus migration occurred in 302 (22%) patients, thrombus growth in 87 (6%), and thrombus resolution in 39 (3%). Intravenous treatment with alteplase was associated with more thrombus migration (adjusted odds ratio, 2.01; CI, 1.29–3.11) and thrombus resolution (adjusted odds ratio, 1.85; CI, 1.22–2.80). Thrombus migration was associated with a lower chance of complete reperfusion (adjusted odds ratio, 0.57; CI, 0.42–0.78) and successful reperfusion (adjusted odds ratio, 0.74; CI, 0.55–0.99). In the subgroup of patients with M1 initial target occlusion, thrombus migration was associated with better functional outcome (adjusted common odds ratio, 1.49; CI, 1.02–2.17), and there was a trend towards better functional outcome in patients with thrombus resolution (adjusted common odds ratio, 2.23; CI, 0.93–5.37). Conclusions— In patients with acute ischemic stroke, thrombus location regularly changes between computed tomography angiography and digital subtraction angiography. Administration of intravenous alteplase increases the chance of thrombus migration and resolution. Thrombus migration is associated with better functional outcome but reduces the rate of complete reperfusion.

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