scholarly journals Effects of Collateral Status on Infarct Distribution Following Endovascular Therapy in Large Vessel Occlusion Stroke

Stroke ◽  
2020 ◽  
Vol 51 (9) ◽  
Author(s):  
Khalid Al-Dasuqi ◽  
Seyedmehdi Payabvash ◽  
Gerardo A. Torres-Flores ◽  
Sumita M. Strander ◽  
Cindy Khanh Nguyen ◽  
...  
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Internal Capsule ◽  
Large Vessel ◽  
Favorable Outcome ◽  
Middle Cerebral Artery Territory ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Deep White Matter ◽  
Border Zones

Background and Purpose: We aim to examine effects of collateral status and post-thrombectomy reperfusion on final infarct distribution and early functional outcome in patients with anterior circulation large vessel occlusion ischemic stroke. Methods: Patients with large vessel occlusion who underwent endovascular intervention were included in this study. All patients had baseline computed tomography angiography and follow-up magnetic resonance imaging. Collateral status was graded according to the criteria proposed by Miteff et al and reperfusion was assessed using the modified Thrombolysis in Cerebral Infarction (mTICI) system. We applied a multivariate voxel-wise general linear model to correlate the distribution of final infarction with collateral status and degree of reperfusion. Early favorable outcome was defined as a discharge modified Rankin Scale score ≤2. Results: Of the 283 patients included, 129 (46%) had good, 97 (34%) had moderate, and 57 (20%) had poor collateral status. Successful reperfusion (mTICI 2b/3) was achieved in 206 (73%) patients. Poor collateral status was associated with infarction of middle cerebral artery border zones, whereas worse reperfusion (mTICI scores 0–2a) was associated with infarction of middle cerebral artery territory deep white matter tracts and the posterior limb of the internal capsule. In multivariate regression models, both mTICI ( P <0.001) and collateral status ( P <0.001) were among independent predictors of final infarct volumes. However, mTICI ( P <0.001), but not collateral status ( P =0.058), predicted favorable outcome at discharge. Conclusions: In this cohort of patients with large vessel occlusion stroke, both the collateral status and endovascular reperfusion were strongly associated with middle cerebral artery territory final infarct volumes. Our findings suggesting that baseline collateral status predominantly affected middle cerebral artery border zones infarction, whereas higher mTICI preserved deep white matter and internal capsule from infarction; may explain why reperfusion success—but not collateral status—was among the independent predictors of favorable outcome at discharge. Infarction of the lentiform nuclei was observed regardless of collateral status or reperfusion success.

scholarly journals Utility of a Y-configured stentriever technique as a rescue method of thrombectomy for an intractable rooted thrombus located on the middle cerebral artery bifurcation: technical note

2017 ◽  
Vol 42 (4) ◽  
pp. E17 ◽  
Author(s):  
Hideo Okada ◽  
Yoshikazu Matsuda ◽  
Joonho Chung ◽  
R. Webster Crowley ◽  
Demetrius K. Lopes
Keyword(s):  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Gold Standard ◽  
Mechanical Thrombectomy ◽  
Technical Note ◽  
Large Vessel ◽  
Alternative Technique ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

Mechanical thrombectomy with stentriever and/or aspiration is the new gold standard for the treatment of acute strokes with large-vessel occlusion. As many as 20% of cases remain refractory to current stentriever and/or aspiration devices. “Saddle clots” obstructing a bifurcation may be a particular challenge for recanalization with conventional techniques and devices. The authors describe an alternative technique to bifurcation occlusions resistant to the conventional mechanical thrombectomy approach in which they simultaneously deployed 2 stentrievers into both branches of an occluded bifurcation. This stentriever Y-configuration was very effective in managing a challenging intracranial bifurcation occlusion.

scholarly journals Validation of a Deep Learning Tool in the Detection of Intracranial Hemorrhage and Large Vessel Occlusion

2021 ◽  
Vol 12 ◽  
Author(s):  
Joel McLouth ◽  
Sebastian Elstrott ◽  
Yasmina Chaibi ◽  
Sarah Quenet ◽  
Peter D. Chang ◽  
...  
Keyword(s):  
Deep Learning ◽  
Middle Cerebral Artery ◽  
Intracranial Hemorrhage ◽  
Cerebral Artery ◽  
The United States ◽  
Large Vessel ◽  
True Positive ◽  
Large Vessel Occlusion ◽  
Learning Tool ◽  
Vessel Occlusion

Purpose: Recently developed machine-learning algorithms have demonstrated strong performance in the detection of intracranial hemorrhage (ICH) and large vessel occlusion (LVO). However, their generalizability is often limited by geographic bias of studies. The aim of this study was to validate a commercially available deep learning-based tool in the detection of both ICH and LVO across multiple hospital sites and vendors throughout the U.S.Materials and Methods: This was a retrospective and multicenter study using anonymized data from two institutions. Eight hundred fourteen non-contrast CT cases and 378 CT angiography cases were analyzed to evaluate ICH and LVO, respectively. The tool's ability to detect and quantify ICH, LVO, and their various subtypes was assessed among multiple CT vendors and hospitals across the United States. Ground truth was based off imaging interpretations from two board-certified neuroradiologists.Results: There were 255 positive and 559 negative ICH cases. Accuracy was 95.6%, sensitivity was 91.4%, and specificity was 97.5% for the ICH tool. ICH was further stratified into the following subtypes: intraparenchymal, intraventricular, epidural/subdural, and subarachnoid with true positive rates of 92.9, 100, 94.3, and 89.9%, respectively. ICH true positive rates by volume [small (&lt;5 mL), medium (5–25 mL), and large (&gt;25 mL)] were 71.8, 100, and 100%, respectively. There were 156 positive and 222 negative LVO cases. The LVO tool demonstrated an accuracy of 98.1%, sensitivity of 98.1%, and specificity of 98.2%. A subset of 55 randomly selected cases were also assessed for LVO detection at various sites, including the distal internal carotid artery, middle cerebral artery M1 segment, proximal middle cerebral artery M2 segment, and distal middle cerebral artery M2 segment with an accuracy of 97.0%, sensitivity of 94.3%, and specificity of 97.4%.Conclusion: Deep learning tools can be effective in the detection of both ICH and LVO across a wide variety of hospital systems. While some limitations were identified, specifically in the detection of small ICH and distal M2 occlusion, this study highlights a deep learning tool that can assist radiologists in the detection of emergent findings in a variety of practice settings.

Acute Middle Cerebral Artery Occlusion

2019 ◽  
pp. 155-164
Author(s):  
Phillip A. Bonney ◽  
Parampreet Singh ◽  
Benjamin Yim ◽  
William J. Mack
Keyword(s):  
Ischemic Stroke ◽  
Middle Cerebral Artery ◽  
Acute Ischemic Stroke ◽  
Middle Cerebral Artery Occlusion ◽  
Cerebral Artery ◽  
Artery Occlusion ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Cerebral Artery Occlusion

Abstract: This chapter addresses the neurosurgical management of stroke due to acute middle cerebral artery occlusion. Large vessel occlusion is a common mechanism of acute ischemic stroke. Mechanical thrombectomy has emerged as an important procedure that drastically improves outcomes in this disease. This chapter discusses the diagnosis and treatment of acute ischemic stroke from large vessel occlusion, including the rapid radiographic evaluation with CT, CTA, MRI, and perfusion imaging. The scoring of the stroke using scales such as the ASPECTS score and their use in decision-making is reviewed. The chapter then discusses treatment with both chemical thrombolysis and mechanical thrombectomy, including the technical aspects of the procedure.

Acute occlusion of the fetal posterior cerebral artery: diagnosis and management paradigms

2021 ◽  
pp. 197140092110193
Author(s):  
Mohamad Abdalkader ◽  
Anurag Sahoo ◽  
Julie G Shulman ◽  
Elie Sader ◽  
Courtney Takahashi ◽  
...  
Keyword(s):  
Endovascular Treatment ◽  
Cerebral Artery ◽  
Mechanical Thrombectomy ◽  
Posterior Cerebral Artery ◽  
Management Strategies ◽  
Artery Occlusion ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Cerebral Artery Occlusion

Background and purpose The diagnosis and management of acute fetal posterior cerebral artery occlusion are challenging. While endovascular treatment is established for anterior circulation large vessel occlusion stroke, little is known about the course of acute fetal posterior cerebral artery occlusions. We report the clinical course, radiological findings and management considerations of acute fetal posterior cerebral artery occlusion stroke. Methods We performed a retrospective review of consecutive patients presenting with acute large vessel occlusion who underwent cerebral angiogram and/or mechanical thrombectomy between January 2015 and January 2021. Patients diagnosed with fetal posterior cerebral artery occlusion were included. Demographic data, clinical presentation, imaging findings and management strategies were reviewed. Results Between January 2015 and January 2021, three patients with fetal posterior cerebral artery occlusion were identified from 400 patients who underwent angiogram and/or mechanical thrombectomy for acute stroke (0.75%). The first patient presented with concomitant fetal posterior cerebral artery and middle cerebral artery occlusions. Thrombectomy was performed with recanalisation of the fetal posterior cerebral artery but the patient died from malignant oedema. The second patient presented with isolated fetal posterior cerebral artery occlusion. No endovascular intervention was performed and the patient was disabled from malignant posterior cerebral artery infarct. The third patient presented with carotid occlusion and was found to have fetal posterior cerebral artery occlusion after internal carotid artery recanalisation. No further intervention was performed. The patient was left with residual contralateral homonymous hemianopia and mild left sided weakness. Conclusion Fetal posterior cerebral artery occlusion is a rare, but potentially disabling, cause of ischaemic stroke. Endovascular treatment is feasible. Further investigation is needed to compare the efficacy of medical versus endovascular management strategies.

scholarly journals Favorable outcome of repeat mechanical thrombectomy in a geriatric patient: illustrative case

2021 ◽  
Vol 1 (24) ◽  
Author(s):  
Ali A. Alsarah ◽  
Omar M. Hussein ◽  
Andrew P. Carlson
Keyword(s):  
Geriatric Patients ◽  
Unusual Case ◽  
Mechanical Thrombectomy ◽  
Large Vessel ◽  
Favorable Outcome ◽  
Illustrative Case ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Common Procedure ◽  
Favorable Neurological Outcome

BACKGROUND The authors presented their experience with a case of repeat thrombectomy in a 93-year-old patient who showed a favorable outcome after recurrent large vessel occlusion treated with emergency mechanical thrombectomy. OBSERVATIONS Mechanical thrombectomy has been proven to be effective in treating large vessel occlusion types of ischemic stroke. Most of the patient populations involved in the thrombectomy-related studies were younger than 80 years. In addition, recurrent mechanical thrombectomy is not a common procedure in clinical practice. This unusual case demonstrated the potential to achieve a favorable outcome with thrombectomy even in a patient older than 85 years with recurrent large vessel occlusion. LESSONS There can be a favorable neurological outcome after one or repeat thrombectomies for geriatric patients older than 90 years, and age should not be a deterrent to treatment.

Proximal hyper-intense vessel sign on initial FLAIR MRI in hyper-acute middle cerebral artery ischemic stroke: a retrospective observational study

2020 ◽  
pp. 028418512094671 ◽  
Author(s):  
Dong Hyuk Shin ◽  
Sang Kuk Han ◽  
Jang Hee Lee ◽  
Pil Cho Choi ◽  
Sang O Park ◽  
...  
Keyword(s):  
Magnetic Resonance Imaging ◽  
Magnetic Resonance ◽  
Middle Cerebral Artery ◽  
Cerebral Artery ◽  
Cerebral Arteries ◽  
Brain Mri ◽  
Large Vessel ◽  
Resonance Imaging ◽  
Vessel Occlusion ◽  
Vessel Stenosis

Background A hyper-intense vessel sign on fluid attenuated inversion recovery magnetic resonance imaging (FHV) represents slow blood flow in the cerebral arteries. Purpose To investigate the relationship between the proximal FHV (pFHV) on initial magnetic resonance imaging (MRI) and the status of the culprit vessel (stenosis, obstruction) in hyper-acute strokes affecting the territory of the middle cerebral artery (MCA). Material and Methods The study participants consisted of 105 patients presenting to the emergency department (ED) with acute MCA infarction within 4.5 h of onset of symptoms. Patients underwent brain MRI within 45 min of arrival at the ED and angiography within 2 h of arrival. Culprit vessel status and presence of a pFHV on initial MRI were investigated retrospectively. Results The pFHV was observed in 71/105 (67.6%) patients who presented with a hyper-acute MCA infarction. All patients with hyper-acute MCA infarction caused by internal carotid artery (90.6% caused by M1 occlusion, 92.9% caused by M2 occlusion) showed a pFHV on initial MRI. After logistic regression analysis, the presence of a pFHV showed significant positive correlation with large vessel occlusion (adjusted odds ratio [OR] 34.533, 95% confidence interval [CI] 9.781–121.926; P < 0.001). A pFHV was not associated with severe large vessel stenosis. Conclusion A pFHV is independently representative of the acute occlusion of intervention-eligible proximal arteries within the territory of the MCA. If a patient with a hyper-acute MCA infarction shows a pFHV, aggressive flow augmentation strategies and early activation of intervention team should be warranted for best patient outcome.

scholarly journals Association of Admission Hyperglycemia with Clinical Outcomes in Japanese Patients with Acute Large Vessel Occlusion Stroke: A post hoc Analysis of the Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism Japan Registry 2

2020 ◽  
pp. 1-8
Author(s):  
Yukako Yazawa ◽  
Tetsuya Ohira ◽  
Ryo Itabashi ◽  
Kazutaka Uchida ◽  
Nobuyuki Sakai ◽  
...  
Keyword(s):  
Functional Outcome ◽  
Clinical Outcomes ◽  
Large Scale ◽  
Asian Population ◽  
Japanese Patients ◽  
Large Vessel ◽  
Favorable Outcome ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Multicenter Registry

<b><i>Introduction:</i></b> Admission hyperglycemia is an indicator of poor functional prognosis in acute stroke, but investigations of its prevalence and effects on the outcomes of acute large vessel occlusion in real-world, large-scale studies are limited, especially in Asian population. <b><i>Objective:</i></b> We aimed to elucidate the relationship between admission hyperglycemia and outcomes in a prospective multicenter registry in Japan. <b><i>Methods:</i></b> We analyzed data from the Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism (RESCUE) Japan Registry 2, which was a prospective, multicenter registry that enrolled patients from 46 centers in Japan. Admission hyperglycemia was defined as blood glucose level &#x3e;140 mg/dL. The relationships between clinical outcomes and admission hyperglycemia were analyzed in all 1,932 assessable patients. A favorable functional outcome, defined as a modified Rankin Scale score of 0–2 at day 90, as well as mortality within 90 days and symptomatic intracranial hemorrhage (SICH) within 72 h, was analyzed. We performed subgroup analyses of the adjusted variables to investigate the association between hyperglycemia and favorable outcome in relation to each variable. <b><i>Results:</i></b> Admission hyperglycemia was present in 687 (35.6%) of the assessable patients and in 420 (26.9%) of the 1,561 patients without diabetes. A favorable outcome was significantly less frequent in the hyperglycemia group than in the no-hyperglycemia group (33.2% vs. 47.6%, adjusted odds ratio [OR]: 0.60, 95% confidence interval [CI]: 0.47–0.76). The mortality rates were 12.8% and 6.8% in the hyperglycemia and no-hyperglycemia groups, respectively. The incidence of SICH within 72 h was higher in the hyperglycemia group than in the no-hyperglycemia group (4.4% vs. 1.9%, adjusted OR: 2.54, 95% CI: 1.36–4.82). Hyperglycemia was associated with unfavorable outcomes in almost all subgroups. <b><i>Conclusions:</i></b> Admission hyperglycemia in Japanese patients with large vessel occlusion stroke is associated with an unfavorable functional outcome at 90 days, mortality within 90 days, and the occurrence of SICH within 72 h.

Abstract TP11: Beyond Large Vessel Occlusion Strokes: Distal Occlusion Thrombectomy

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Jonathan A Grossberg ◽  
Leticia C Rebello ◽  
Diogo C Haussen ◽  
Mehdi Bouslama ◽  
Meredith Bowen ◽  
...  
Keyword(s):  
Cerebral Artery ◽  
Endovascular Therapy ◽  
Standard Of Care ◽  
Primary Treatment ◽  
Large Vessel ◽  
Treatment Modalities ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Distal Occlusion ◽  
Iv Tpa

Introduction: Endovascular therapy is the standard of care for the treatment of proximal large vessel occlusion strokes (LVOS). Its safety and efficacy in the treatment of distal intracranial occlusions has not been well studied. Methods: We retrospectively reviewed a prospectively collected endovascular database (September 2010-December 2015, n=898) for all patients with distal intracranial occlusions treated with endovascular therapy. Distal occlusions were defined as any occlusion of the anterior cerebral artery (ACA), any occlusion of the posterior cerebral artery (PCA), or any occlusion at or distal to the middle cerebral artery (MCA)-M3 opercular segment. Results: Distal occlusions were treated in 70 patients. The mean age was 66+/-14 and 57% of the patients were male. Thirty-one (44%) of the patients received IV-tPA. The median pre-procedure NIHSS was 19 (IQR, 13-23). The distal occlusion was the primary treatment location in 54 patients and in 16 patients the distal occlusion was treated as a rescue strategy after successful treatment of a proximal LVOS. The locations of the primary cases were MCA-M3 (n=21), ACA with a concomitant MCA-M1 or MCA-M2 (n=16), ACA alone (n=9), PCA (n=6), and ACA with a concomitant MCA-M3 (n=2). The locations of the rescue cases were MCA-M3 (n=8), ACA (n=7), and both MCA-M3 and ACA (n=1). The most common treatment modalities employed were intra-arterial tPA (n=37, 52%), small (3mm) stent-retrievers (n=24, 33%), and thromboaspiration (n=30, 42%). Near or complete reperfusion (mTICI 2b-3) was achieved in 56 cases (80%). Overall, there were 5 (7%) cases of any parenchymal hematoma (PH). However, two of the PHs were in patients with both a MCA-M1 and an ACA occlusion, and both of these hemorrhages were in the MCA territory. Thus only 3 PHs (4.3%) occurred in the territory of the treated distal occlusion with two of these patients also receiving IV tPA. At 90 days, 24 patients (40%) had a mRS of 0-2 and 13 (21%) had died. Conclusions: Distal intracranial occlusions can be treated safely and successfully with endovascular therapy. Although promising our results need to be corroborated by larger prospective controlled studies.

Abstract T MP1: Predictive Factors of Favorable Outcome in Patients With Acute Large Vessel Occlusion

Stroke ◽  
2014 ◽  
Vol 45 (suppl_1) ◽  
Author(s):  
Shinichi Yoshimura ◽  
Nobuyuki Sakai ◽  
Yasushi Okada ◽  
Kazuo Kitagawa ◽  
Kazumi Kimura ◽  
...  
Keyword(s):  
Free Radical ◽  
Predictive Factors ◽  
Free Radical Scavenger ◽  
Large Vessel ◽  
Favorable Outcome ◽  
Radical Scavenger ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Number Of Patients ◽  
Iv Tpa

Background: The data of the nationwide prospective registry of acute cerebral large vessel occlusion (RESCUE-Japan Registry) was analyzed to know the predictive factors of favorable outcome at 90 days Methods: In this registry, patients with acute cerebral large vessel occlusion admitted within 24 h after onset were prospectively registered. The effect of various factors including endovascular treatment (EVT), intravenous tissue plasminogen activator (IV-tPA), and other medication on favorable outcome (modified Rankin scale 0-2) was analyzed. Results: A total of 1,315 patients were analyzed. The number of patients in favorable outcome was 422 (32.1%). Logistic regression analysis revealed that higher NIHSS (OR 0.875, 95%CI 0.858-0.894) and advanced age (OR 0.963, 95% CI 0.952-0.975) were significantly related to unfavorable outcome (Fig. 1). In contrast, IV-tPA (OR 2.489, 95% CI 1.867-3.319), EVT (OR 1.375, 95% CI 1.013-1.865), and free radical scavenger, edaravon, (OR 1.483, 95% CI 1.027-2.143) were significantly associated with favorable outcome. Combination with IV-tPA or EVT with free radical scavenger was better than without it (Fig. 2). Conclusions: This analysis indicated that IV-tPA, EVT and free radical scavenger were effective to obtain favorable outcome in the patients with acute large vessel occlusion. Combination with free radical scavenger was also effective.

Impact of Strategy on Clinical Outcome in Large Vessel Occlusion Stroke Successfully Reperfused: ETIS Registry Results

Stroke ◽  
2021 ◽  
Author(s):  
Marian Douarinou ◽  
Benjamin Gory ◽  
Arturo Consoli ◽  
Bertrand Lapergue ◽  
Maeva Kyheng ◽  
...  
Keyword(s):  
Odds Ratio ◽  
Therapy Group ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Favorable Outcome ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Bridging Therapy ◽  
Anterior Circulation ◽  
Vessel Occlusion

Background and Purpose: Approximately half of the patients with acute ischemic stroke due to anterior circulation large vessel occlusion do not achieve functional independence despite successful reperfusion. We aimed to determine influence of reperfusion strategy (bridging therapy, intravenous thrombolysis alone, or mechanical thrombectomy alone) on clinical outcomes in this population. Methods: From ongoing, prospective, multicenter, observational Endovascular Treatment in Ischemic Stroke registry in France, all patients with anterior circulation large vessel occlusion who achieved successful reperfusion (modified Thrombolysis in Cerebral Infarction 2b-3) following reperfusion therapy were included. Primary end point was favorable outcome, defined as 90-day modified Rankin Scale score ≤2. Patient groups were compared using those treated with bridging therapy as reference. Differences in baseline characteristics were reduced after propensity score-matching, with a maximum absolute standardized difference of 14% for occlusion site. Results: Among 1872 patients included, 970 (51.8%) received bridging therapy, 128 (6.8%) received intravenous thrombolysis alone, and the remaining 774 (41.4%) received MT alone. The rate of favorable outcome was comparable between groups. Excellent outcome (90-day modified Rankin Scale score 0–1) was achieved more frequently in the bridging therapy group compared with the MT alone (odds ratio after propensity score-matching, 0.70 [95% CI, 0.50–0.96]). Regarding safety outcomes, hemorrhagic complications were similar between the groups, but 90-day mortality was significantly higher in the MT alone group compared with the bridging therapy group (odds ratio, 1.60 [95% CI, 1.09–2.37]). Conclusions: This real-world observational study of patients with anterior circulation large vessel occlusion demonstrated a similar rate of favorable outcome following successful reperfusion with different therapeutic strategies. However, our results suggest that bridging therapy compared with MT alone is significantly associated with excellent clinical outcome and lower mortality. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT03776877.

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