Reduced Leukoaraiosis, Noncardiac Embolic Stroke Etiology, and Shorter Thrombus Length Indicate Good Leptomeningeal Collateral Flow in Embolic Large-Vessel Occlusion

2021 ◽  
Author(s):  
T. Hashimoto ◽  
T. Kunieda ◽  
T. Honda ◽  
F. Scalzo ◽  
L. Ali ◽  
...  
Keyword(s):  
Embolic Stroke ◽  
Large Vessel ◽  
Collateral Flow ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Stroke Etiology

Abstract P558: Identification of Embolic Stroke in Patients With Large Vessel Occlusion

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Lan Hong ◽  
Longting Lin ◽  
Gang Li ◽  
Jianhong Yang ◽  
Geng Yu ◽  
...  
Keyword(s):  
Perfusion Imaging ◽  
Delay Time ◽  
Validation Cohort ◽  
Embolic Stroke ◽  
Large Vessel ◽  
Smoking History ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Derivation Cohort ◽  
History Of

Objective: To develop a simple and objective score using clinical variables and quantified perfusion measures to identify embolic stroke with large vessel occlusions. Methods: Eligible patients from the Chinese centers participating in the International Stroke Perfusion Imaging Registry were included in this study. Patients were split into a derivation cohort (n=213) and a validation cohort (n=116). A score was developed according to the coefficients of independent predictors of embolic stroke from stepwise logistic regression model in the derivation cohort. The performance of the score was validated by assessing its discrimination and calibration. Additionally, a comparison between the area under curve (AUC) of history of atrial fibrillation (AF) alone and history of AF plus the score was also conducted. Results: The independent predictors of embolic stroke made up the Chinese Embolic Stroke Score (CHESS). There were: age (≥64 years, 1 point), non-smoking history (1 point), non-hypertension history (1 point) , baseline NIH Stroke Scale (≥14, 1 point) and delay time>6s volume/delay time>3s volume on perfusion imaging (≥0.23, 2 points). The AUC of CHESS in the derivation cohort and validation cohort were 0.80 and 0.72 respectively. Calibration tests indicated high agreement between predicted and observed probabilities. The AUC of AF-plus-CHESS compared to history of AF alone was significant (derivation cohort P<0.001; validation cohort P=0.01). Conclusions: In a Chinese population, CHESS reliably and independently identified embolic stroke as the cause of large vessel occlusion.

scholarly journals Better Collaterals Are Independently Associated With Post-Thrombolysis Recanalization Before Thrombectomy

Stroke ◽  
2019 ◽  
Vol 50 (4) ◽  
pp. 867-872 ◽  
Author(s):  
Pierre Seners ◽  
Pauline Roca ◽  
Laurence Legrand ◽  
Guillaume Turc ◽  
Jean-Philippe Cottier ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Multivariable Analysis ◽  
Brain Magnetic Resonance Imaging ◽  
Intravenous Thrombolysis ◽  
Large Vessel ◽  
Dynamic Susceptibility ◽  
Collateral Flow ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Perfusion Weighted Imaging

Background and Purpose— In acute stroke patients with large vessel occlusion, the goal of intravenous thrombolysis (IVT) is to achieve early recanalization (ER). Apart from occlusion site and thrombus length, predictors of early post-IVT recanalization are poorly known. Better collaterals might also facilitate ER, for instance, by improving delivery of the thrombolytic agent to both ends of the thrombus. In this proof-of-concept study, we tested the hypothesis that good collaterals independently predict post-IVT recanalization before thrombectomy. Methods— Patients from the registries of 6 French stroke centers with the following criteria were included: (1) acute stroke with large vessel occlusion treated with IVT and referred for thrombectomy between May 2015 and March 2017; (2) pre-IVT brain magnetic resonance imaging, including diffusion-weighted imaging, T2*, MR angiography, and dynamic susceptibility contrast perfusion-weighted imaging; and (3) ER evaluated ≤3 hours from IVT start on either first angiographic run or noninvasive imaging. A collateral flow map derived from perfusion-weighted imaging source data was automatically generated, replicating a previously validated method. Thrombus length was measured on T2*-based susceptibility vessel sign. Results— Of 224 eligible patients, 37 (16%) experienced ER. ER occurred in 10 of 83 (12%), 17 of 116 (15%), and 10 of 25 (40%) patients with poor/moderate, good, and excellent collaterals, respectively. In multivariable analysis, better collaterals were independently associated with ER ( P =0.029), together with shorter thrombus ( P <0.001) and more distal occlusion site ( P =0.010). Conclusions— In our sample of patients with stroke imaged with perfusion-weighted imaging before IVT and intended for thrombectomy, better collaterals were independently associated with post-IVT recanalization, supporting our hypothesis. These findings strengthen the idea that advanced imaging may play a key role for personalized medicine in identifying patients with large vessel occlusion most likely to benefit from IVT in the thrombectomy era.

Abstract P340: Chronic Cerebrovascular Damage and Acute Embolic Mechanisms Associated With Acute Leptomeningeal Collateral Flow in Embolic Large Vessel Occlusion

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Tetsuya Hashimoto ◽  
Takenobu Kunieda ◽  
Tristan Honda ◽  
Fabien Scalzo ◽  
Latisha K Sharma ◽  
...  
Keyword(s):  
Time Course ◽  
Multivariate Logistic Regression Analysis ◽  
Blood Perfusion ◽  
Large Vessel ◽  
Cardioembolic Stroke ◽  
Collateral Flow ◽  
Large Vessel Occlusion ◽  
Stroke Subtype ◽  
Anterior Circulation ◽  
Vessel Occlusion

Background and Purpose: Acute leptomeningeal collateral flow is vital to maintain blood perfusion to penumbral tissue in acute ischemic stroke due to large vessel occlusion (LVO). However, the degree of this collateral flow differs among patients. Patient premorbid factors as well as factors caused by the mechanisms of stroke are expected to be associated with this collateral flow. We aimed to investigate the clinical determinants of acute leptomeningeal collateral flow in embolic LVO. Methods: Among consecutive stroke patients caused by acute embolic anterior circulation LVO, we retrospectively reviewed 108 patients who underwent evaluation of acute leptomeningeal collateral status (CS) on pretreatment CTA admitted from January 2015 to December 2019. Both premorbid information including cerebrovascular risk factors and leukoaraiosis evaluated by the total white matter (WM) Fazekas score on MRI, which was calculated as periventricular plus deep WM scores, and stroke related information including stroke subtypes, severity, time course, and occlusive thrombus characteristics were collected. Among thrombus characteristics, thrombus length was measured by tracing the filling defect of contrast on CTA. The clinical determinants of good leptomeningeal CS (> 50% collateral filling of the occluded territory) were analyzed. Results: CS was good in 67 patients (62%). On multivariate logistic regression analysis, cardioembolic stroke subtype was negatively related (OR, 0.170; 95% CI, 0.022-0.868), and mild leukoaraiosis (total WM Fazekas scores of 0-2) was positively related (OR, 9.57; 95% CI, 2.49-47.75) to good CS. On subgroup analysis limited to 82 patients with cardioembolic stroke, shorter thrombus length (OR, 0.913 per mm increase; 95% CI, 0.819-0.999) as well as mild leukoaraiosis (OR, 5.79; 95% CI, 1.40-29.61) were independently related to good CS. Conclusions: Premorbid leukoaraiosis and cardioembolic etiology are determinants of acute leptomeningeal collateral flow in embolic LVO. In addition, thrombus length is also a determinant of collateral flow in cardioembolic LVO. These findings indicate that a combination of chronic cerebrovascular damage and acute embolic mechanisms could determine the degree of leptomeningeal collateral flow.

scholarly journals Thrombectomy for Treatment of Acute Stroke in the COVID-19 Pandemic

2020 ◽  
pp. 1-6
Author(s):  
Panagiotis Papanagiotou ◽  
Guillermo Parrilla ◽  
L. Creed Pettigrew
Keyword(s):  
Acute Stroke ◽  
Embolic Stroke ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Novel Coronavirus

This commentary will focus on the role of thrombectomy for the treatment of embolic stroke during the 2019 novel coronavirus disease (COVID-19). We will begin with review of recently promulgated guidelines for use of thrombectomy in COVID-19-associated stroke. We will then survey the reported experience of thrombectomy applied to treatment of large-vessel occlusion (LVO) stroke in COVID-19. We will conclude by discussing unusual challenges confronted by neuro-interventionalists seeking to perform thrombectomy in COVID-19 patients with acute LVO stroke.

scholarly journals First approach to distinguish between cardiac and arteriosclerotic emboli of individual stroke patients applying the histological THROMBEX-classification rule

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Florian C. Roessler ◽  
Nicolas Kalms ◽  
Florian Jann ◽  
Andrè Kemmling ◽  
Julika Ribbat-Idel ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Large Vessel ◽  
Classification Rule ◽  
Prevention Measures ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Rule Based ◽  
Stroke Etiology ◽  
Histopathological Investigation

AbstractEndovascular treatment of strokes caused by large vessel occlusion enables the histopathological investigation of the retrieved embolus, possibly providing a novel opportunity to contribute to the diagnostic workup of etiology and to define secondary prevention measures in strokes with uncertain genesis. We aimed to develop a classification rule based on pathophysiological considerations and adjustment to reference thrombi for distinction between cardiac and arteriosclerotic emboli and to validate this classification rule on a patient cohort. From 125 patients with stroke due to large vessel occlusion and thrombectomy, 82 patients with known etiology (55 cardioembolic and 27 arterioembolic strokes) were included. The corresponding emboli were histologically evaluated by two raters blinded to the etiology of stroke by means of a novel classification rule. Presumed etiology and classification results were compared. Agreement concerning cardiac emboli was 72.2% (95% CI: 58.4–83.5) for rater I and 78.2% (95% CI: 65.0–88.2) for rater II. Agreement concerning arteriosclerotic emboli was 70.4% (95% CI: 49.8–86.3) for rater I and 74.1% (95% CI: 53.7–88.9) for rater II. Overall agreement reached 71.6% (95% CI: 60.5–81.1) for rater I and 76.8% (95% CI: 66.2–85.4) for rater II. Within the limits of generally restricted accuracy of histological evaluations, the classification rule differentiates between cardiac and arteriosclerotic emboli of acute ischemic stroke patients. Further improvement is needed to provide valuable complementary data for stroke etiology workup.

Flow augmentation STA-MCA bypass evaluation for patients with acute stroke and unilateral large vessel occlusion: a proposal for an urgent bypass flowchart

2022 ◽  
pp. 1-9
Keyword(s):  
Acute Stroke ◽  
Scale Score ◽  
Collateral Circulation ◽  
Positive Impact ◽  
Blood Oxygenation ◽  
Cerebrovascular Reactivity ◽  
Large Vessel ◽  
Collateral Flow ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion

OBJECTIVE Endovascular recanalization trials have shown a positive impact on the preservation of ischemic penumbra in patients with acute large vessel occlusion (LVO). The concept of penumbra salvation can be extended to surgical revascularization with bypass in highly selected patients. For selecting these patients, the authors propose a flowchart based on multimodal MRI. METHODS All patients with acute stroke and persisting internal carotid artery (ICA) or M1 occlusion after intravenous lysis or mechanical thrombectomy undergo advanced neuroimaging in a time window of 72 hours after stroke onset including perfusion MRI, blood oxygenation level–dependent functional MRI to evaluate cerebrovascular reactivity (BOLD-CVR), and noninvasive optimal vessel analysis (NOVA) quantitative MRA to assess collateral circulation. RESULTS Symptomatic patients exhibiting persistent hemodynamic impairment and insufficient collateral circulation could benefit from bypass surgery. According to the flowchart, a bypass is considered for patients 1) with low or moderate neurological impairment (National Institutes of Health Stroke Scale score 1–15, modified Rankin Scale score ≤ 3), 2) without large or malignant stroke, 3) without intracranial hemorrhage, 4) with MR perfusion/diffusion mismatch > 120%, 5) with paradoxical BOLD-CVR in the occluded vascular territory, and 6) with insufficient collateral circulation. CONCLUSIONS The proposed flowchart is based on the patient’s clinical condition and multimodal MR neuroimaging and aims to select patients with acute stroke due to LVO and persistent inadequate collateral flow, who could benefit from urgent bypass.

Abstract TP82: Factors Associated With Good Collateral Flow in Acute Stroke Patients With Large Vessel Occlusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Pierre Seners ◽  
Pauline Roca ◽  
Laurence Legrand ◽  
Guillaume Turc ◽  
Catherine Oppenheim ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Large Vessel ◽  
Stroke Severity ◽  
Lesion Volume ◽  
Dynamic Susceptibility ◽  
Collateral Flow ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Factors Associated ◽  
Tandem Occlusion

Introduction: Retrograde collateral flow is critical to maintain tissue perfusion despite large vessel occlusion. However, the premorbid factors associated with good collateral flow remain unclear, with substantial discrepancies in the literature. Methods: Patients from the registries of 6 French stroke centres with the following criteria were included: (1) acute stroke with isolated M1 occlusion ( i.e , without tandem occlusion) referred for thrombectomy between May 2015 and March 2017; and (2) baseline brain MRI, including diffusion weighted imaging, MR-angiography and dynamic susceptibility-contrast perfusion-weighted imaging (PWI). A collateral flow map derived from PWI source data was automatically generated, replicating Kim et al’s previously validated method (Ann. Neurol., 2014). Collateral flow was dichotomized into good and poor. The association between good collateral flow and baseline clinical, biological and radiological variables was studied. Results: One hundred and sixteen patients were included, of which 66 (57%) had good collaterals. As expected, the latter patients had lower admission NIHSS (median: 15 vs . 18, P=0.005) and lower baseline DWI lesion volume (median: 7ml vs . 32ml, P<0.001) than patient with poor collaterals. Onset-to-imaging delay and M1 occlusion site (proximal vs . distal) were similar in both groups (123min vs . 118min, P=0.75; 70% vs. 68%, P=0.85, respectively). There was no significant (P>0.05) difference in gender, age, history of hypertension or diabetes, current smoking, baseline blood glucose and use of statins or antiplatelets between the good and poor collaterals groups. Conclusions: Despite the expected association between PWI-derived collateral flow and baseline clinical and radiological stroke severity in our sample of acute M1 occlusions, there was no association with premorbid factors previously found associated in some -but not all- studies. Our findings suggest that collateral flow is predominantly explained by genetic factors.

Effect of stroke etiology on endovascular thrombectomy with or without intravenous alteplase: a subgroup analysis of DIRECT-MT

2022 ◽  
pp. neurintsurg-2021-018275
Author(s):  
Pengfei Xing ◽  
Xiaoxi Zhang ◽  
Hongjian Shen ◽  
Fang Shen ◽  
Lei Zhang ◽  
...  
Keyword(s):  
Treatment Strategy ◽  
Combined Therapy ◽  
Large Vessel ◽  
Large Artery ◽  
Efficacy And Safety ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Stroke Etiology ◽  
Ordinal Logistic Regression Analysis ◽  
Intravenous Alteplase

BackgroundStroke etiology might influence the clinical outcomes in patients with large vessel occlusion receiving endovascular treatment (EVT) with or without thrombolysis.ObjectiveTo examine whether stroke etiology resulted in different efficacy and safety in patients treated with EVT-alone or EVT preceded by intravenous alteplase (combined therapy).MethodsWe assessed the efficacy and safety of treatment strategy based on prespecified stroke etiology, cardioembolism (CE), large-artery atherosclerosis (LAA), and undetermined cause (UC) for patients enrolled in the DIRECT-MT trial. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Multivariate ordinal logistic regression analysis was used to calculate the adjusted common OR for a shift of better mRS score for EVT-alone versus combined therapy. A term was entered to test for interaction.ResultsIn this study, 656 patients were grouped into three prespecified stroke etiologic subgroups. The adjusted common ORs for improvement in the 90-day ordinal mRS score with EVT-alone were 1.2 (95% CI 0.8 to 1.8) for CE, 1.6 (95% CI 0.8 to 3.3) for LAA, and 0.8 (95% CI 0.5 to 1.3) for UC. Compared with CE, EVT-alone was more likely to result in an mRS score of 0–1 (pinteraction=0.047) and extended Thrombolysis in Cerebral Infarction ≥2b (pinteraction=0.041) in the LAA group. The differences in mortality and symptomatic intracranial hemorrhage within 90 days were not significant between the subgroups (p＞0.05).ConclusionsThe results did not support the hypothesis that a specific treatment strategy based on stroke etiology should be used for patients with large vessel occlusion (NCT03469206).

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