Prognostic importance of CT ASPECTS and CT perfusion measures of infarction in anterior emergent large vessel occlusions

BackgroundAge, neurologic deficits, core volume (CV), and clinical core or radiographic mismatch are considered in selection for endovascular therapy (ET) in anterior circulation emergent large vessel occlusion (aELVO). Semiquantitative CV estimation by Alberta Stroke Programme Early CT Score (CT ASPECTS) and quantitative CV estimation by CT perfusion (CTP) are both used in selection paradigms.ObjectiveTo compare the prognostic value of CTP CV with CT ASPECTS in aELVO.MethodsPatients in an institutional endovascular registry who had aELVO, pre-ET National Institutes of Health Stroke Scale (NIHSS) score, non-contrast CT head and CTP imaging, and prospectively collected 3-month modified Rankin Scale (mRS) score were included. Age- and NIHSS-adjusted models, including either CT ASPECTS or CTP volumes (relative cerebral blood flow <30% of normal tissue, total hypoperfusion, and radiographic mismatch), were compared using receiver operator characteristic analyses.ResultsWe included 508 patients with aELVO (60.8% M1 middle cerebral artery, 34% internal carotid artery, mean age 64.1±15.3 years, median baseline NIHSS score 16 (12–20), median baseline CT ASPECTS 8 (7–9), mean CV 16.7±24.8 mL). Age, pre-ET NIHSS, CT ASPECTS, CV, hypoperfusion, and perfusion imaging mismatch volumes were predictors of good outcome (mRS score 0–2). There were no differences in prognostic accuracies between reference (age, baseline NIHSS, CT ASPECTS; area under the curve (AUC)=0.76) and additional models incorporating combinations of age, NIHSS, and CTP metrics including CV, total hypoperfusion or mismatch volume (AUCs 0.72–0.75). Predicted outcomes from CT ASPECTS or CTP CV-based models had excellent agreement (R2=0.84, p<0.001).ConclusionsIncorporating CTP measures of core or penumbral volume, instead of CT ASPECTS, did not improve prognostication of 3-month outcomes, suggesting prognostic equivalence of CT ASPECTS and CTP CV.

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Endovascular Therapy for Large Vessel Stroke in the Elderly: Hope in the New Stroke Era

Cerebrovascular Diseases ◽

10.1159/000446852 ◽

2016 ◽

Vol 42 (5-6) ◽

pp. 421-427 ◽

Cited By ~ 10

Author(s):

Andrey Lima ◽

Diogo C. Haussen ◽

Leticia C. Rebello ◽

Seena Dehkharghani ◽

Jonathan Grossberg ◽

...

Keyword(s):

Elderly Patients ◽

Ct Perfusion ◽

Infarct Volume ◽

The Elderly ◽

Outcome Data ◽

Large Vessel ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Nihss Score ◽

Good Outcome

Background and Purpose: Acute ischemic stroke (AIS) in the elderly encompasses approximately one-third of all AIS cases. Outcome data have been for the most part discouraging in this population. We aim to evaluate the outcomes in a large contemporary series of elderly patients treated with thrombectomy. Methods: Retrospective analysis of a single-center endovascular database for consecutive elderly (≥80 years) patients treated for anterior circulation large vessel occlusion AIS between September 2010 and April 2015. Univariate- and multivariate analyses were performed to identify the predictors of good clinical outcome (90-day modified Ranking Scale [mRS] ≤2). Receiver operating characteristic curves were used to calculate the optimal final infarct volume (FIV) threshold to predict good outcomes. Results: A total of 111 patients met our inclusion criteria (mean age 84.8 ± 4.2 years; National Institutes of Health Stroke Scale [NIHSS] score 19.1 ± 5.6; time from last-known normal to puncture, 349.6 ± 246.6 min; 33% male; 68% Alberta Stroke Program Early CT Score [ASPECTS] ≥8). The rates of successful reperfusion (modified treatment in cerebral ischemia ≥2b), symptomatic intracranial hemorrhage and 90-day mortality were 80%, 7% and 41%, respectively. The overall rate of good outcome was 29% (n = 32/111) but was 52% (n = 13/25) in patients with baseline mRS score of 0-2 who were selected based on CT perfusion and treated with stent retrievers. On multivariate analysis, only ASPECTS (OR 2.17; 95% CI 1.28-3.67.7; p = 0.004) and baseline NIHSS score (OR 0.87; 95% CI 0.77-0.97; p = 0.013) were independently associated with good outcome. A FIV ≤16 ml demonstrated the greatest accuracy for identifying good outcomes (sensitivity 75.0%, specificity 82.6%). Conclusions: Our results are encouraging demonstrating nearly one-third of elderly patients achieving full independence at 90 days. Contemporary treatment paradigms employing optimized patient selection and modern thrombectomy technology may result in even better outcomes.

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Abstract 118: Diffusion Lesion Volume Reduction after Recanalization Therapy for Anterior Circulation Stroke with Major Vessel Occlusion: Analysis from the RESCUE-Japan Registry Study

Stroke ◽

10.1161/str.45.suppl_1.118 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Mikito Hayakawa ◽

Hiroshi Yamagami ◽

Kazunori Toyoda ◽

Yuji Matsumaru ◽

Yukiko Enomoto ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Volume Reduction ◽

Lesion Volume ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Nihss Score ◽

Median Baseline ◽

Point Reduction ◽

Major Vessel

Objective: Although Diffusion-weighted imaging (DWI) lesions are commonly irreversible, DWI lesion volume reduction (DVR) is occasionally observed. We investigated clinical significance and predictors of DVR in acute stroke patients with major vessel occlusion receiving recanalization therapy (RT). Methods: The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan registry prospectively registered 1,442 stroke patients with major vessel occlusion who were admitted to 84 Japanese stroke centers within 24 hours after onset from July 2010 to June 2011. We retrospectively analyzed all patients with the internal carotid artery or middle cerebral artery (M1 or M2 segments occlusions receiving RT and undergoing MRI both on admission and at 24 hours after onset from the registry. We defined DVR as a 1 or more-point reduction of the DWI-Alberta Stroke Program Early CT Score (ASPECTS), and CT-DWI mismatch (CTDM) as a 2 or more-point lower DWI-ASPECTS than CT-ASPECTS on admission. Reperfusion was defined as TICI grade 2b-3 on catheter angiography or modified Mori grade 3 on MRA immediately after RT. Dramatic recovery (DR) was defined as a 10 or more-point reduction or a total NIHSS score of 0-1 at 24 hours, and favorable outcome (FO) defined as a mRS score 0-2 at 3 months. Results: A total of 390 patients (215 men, 72 years old,) was included. Median baseline NIHSS score was 16 (IQR 10-19) and median baseline DWI-ASPECTS was 8 (6-9). CTDM was seen in 92 patients (28%) on admission. Intravenous thrombolysis and endovascular therapy were performed in 246 patients (63%) and 223 patients (57%), respectively. Reperfusion was obtained in 170 patients (51%). DVR was seen in 51 patients (13%). Eighty-eight patients (23%) obtained DR and 158 patients (41%) achieved FO. On multivariate analyses, DVR was significantly related to DR (OR 3.8, 95%CI 1.5-10) and FO (4.6, 1.8-12). CTDM was an independent predictor of DVR (OR 2.5, 95% CI 1.1-5.8). Conclusions: DVR was significantly related to DR and FO. CTDM is a rough predictor of DVR of which area is considered as a “DWI-bright” ischemic penumbra, and might be a useful marker to identify the adequate candidates for RT in spite of relatively large DWI lesions.

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Abstract WP290: Endovascular Treatment Of In-hospital Strokes: An Open Book

Stroke ◽

10.1161/str.44.suppl_1.awp290 ◽

2013 ◽

Vol 44 (suppl_1) ◽

Author(s):

Dolora Wisco ◽

KEN UCHINO ◽

ESTEBAN CHENG CHING ◽

Shazia Alam ◽

SHUMEI MAN ◽

...

Keyword(s):

Mechanical Thrombectomy ◽

Patient Characteristics ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Valve Repair ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Ct Brain ◽

Contrast Ct ◽

Iv Tpa

INTRODUCTION: In-hospital stroke (IHS) presents a different treatment challenge than out of hospital stroke. IHS often has contraindication to IV tPA, such as such as recent surgery, MI, and use of anticoagulation. Intra-arterial therapy (IAT) with tPA and/or mechanical thrombectomy is an option for large vessel acute IHS with contraindications to or fail to recanalize with IV tPA, to restore cerebral perfusion. Objective: To assess the characteristics and outcomes of patients with in-hospital strokes large vessel occlusion who receive IAT. Methods: From our database of patients from 1/1/2008 to 12/31/2011 who had IAT for an acute stroke due to large vessel occlusion, in hospital strokes and out of hospital strokes were identified. Patient characteristics, imaging, and outcomes were retrospectively collected. Statistical analysis was performed on JMP 9.0. Result: 151 patients were included, 23 (15%) were in-hospital strokes (IHS) and 128 (85%) were out of hospital strokes (OHS). Initial median NIHSS of 17 and 16 respectively (p=0.3). IHS were frequently in the cardiology/CTS service (14, 60%) for CHF and cardiac valve repair (12, 52%). Other comorbidities present were atrial fibrillation (68%), hypertension (68%), and hyperlipidemia (56%). Seven (30%) were on warfarin prior to admission, but all had subtherapeutic INR. Three (13%) IHS received IV tPA. The time from last known well (LKW) to non-contrast CT brain was 80 min, and to CTA was 113 min in IHS, and 147 min and 229 min respectively in OHS (p = 0.0003). 20 (87%) had lesion in the anterior circulation. LKW to IAT recanalization was 248 min in IHS, compared to 375 min in OHS. Recanalization rate was 68% for IHS and 81% for OHS (p=0.2). Nine (39%) IHS had favorable mRS of 1 to 3 at 90 days, compared to 44 (34%) OHS, (p = 0.6). Despite faster recanalization time, there was no difference in the 90 day mortality of IHS v OHS (48% vs 30%, p = 0.1), and IHS had greater 1 year mortality (65% vs 30%, p = 0.005). Discussion: In-hospital strokes have higher mortality than out of hospital strokes. There is a role for IAT In carefully selected IHS with large vessel occlusion. A multicenter study is needed to reveal the characteristics of IHS patients who may benefit from IAT.

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Abstract TP77: Impact of Time and Aspects on Clinical Core Mismatch in Large Vessel Occlusion Strokes

Stroke ◽

10.1161/str.51.suppl_1.tp77 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Shashvat Desai ◽

Bradley J Molyneaux ◽

Marcelo Rocha ◽

Matthew Starr ◽

Tudor G Jovin ◽

...

Keyword(s):

Patient Selection ◽

Time Window ◽

Ct Perfusion ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Ct Head ◽

Ischemic Core ◽

The Impact ◽

Core Volume

Introduction: Patient selection for endovascular thrombectomy (EVT) for anterior circulation large vessel occlusion (LVO) strokes in the 6-24-hour time window is dependent on delineating clinical core mismatch (CCM) as defined by DAWN trial criteria. In contrast, patient selection in the early window (0-6 hours) can be performed using ASPECTS on CT head. We aim to determine the prevalence of DAWN-CCM in LVO strokes and the impact of time and ASPECTS. Methods: Retrospective analysis of large vessel occlusion [internal carotid and middle cerebral artery-M1] strokes at a CSC. Consecutive patients who underwent CT perfusion or MRI within 120 minutes of CT head were included in the study (treated and untreated). Ischemic core volume was assessed using RAPID [IschemaView] and ASPECTS using automated ASPECTS [Brainomix]. CCM was defined using DAWN trial criteria [DAWN-CCM: NIHSS ≥10 and core <31 ml, NIHSS ≥20 and core <51 ml]. Results: A total of 116 patients were included. Mean age was 71 ±14 and 62% were females. Mean ischemic core volume and median ASPECTS were 46 ±65 ml and 8 (6-9), respectively. In patients with NIHSS score ≥10 (98), 57% had DAWN-CCM in the 0-24-hour window. Proportion of patients with DAWN-CCM in 6-24-hour window was 70% (6-12 hours), 50% (12-18 hours), and 50% (18-24 hours) [p=0.35]. Proportion of patients with DAWN-CCM by ASPECTS group was 88% (ASPECTS 9-10), 64% (ASPECTS 6-8) and 13% (ASPECTS 0-5) [p=<0.01] (Figure 1). Probability of DAWN-CCM declines by 7% for every 2 hours increase in TLKW to imaging, and by 13% for every 1-point decrease in ASPECTS. Conclusion: Approximately 57% of LVO strokes have clinical core mismatch. LVO strokes with DAWN-CCM decline with increasing time and decreasing ASPECTS. ASPECTS alone may be sufficient to identify patients with DAWN-CCM in a resource limited setting and avoid time consuming advanced imaging.

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Prospective Endovascular Treatment in Acute Ischemic Stroke Evaluating Non-Contrast Head CT versus CT Perfusion (PLEASE No CTP)

Interventional Neurology ◽

10.1159/000496615 ◽

2019 ◽

Vol 8 (2-6) ◽

pp. 116-122

Author(s):

Ameer E. Hassan ◽

Hafsah Shamim ◽

Haralabos Zacharatos ◽

Saqib A. Chaudhry ◽

Christina Sanchez ◽

...

Keyword(s):

Computed Tomography ◽

Ischemic Stroke ◽

Endovascular Treatment ◽

Acute Ischemic Stroke ◽

Symptom Onset ◽

Ct Perfusion ◽

Treatment Decision ◽

Anterior Circulation ◽

Nihss Score ◽

Contrast Ct

Background: Studies have shown a lack of agreement of computed tomography perfusion (CTP) in the selection of acute ischemic stroke (AIS) patients for endovascular treatment. Purpose: To demonstrate whether non-contrast computed tomography (CT) within 8 h of symptom onset is comparable to CTP imaging. Methods: Prospective study of consecutive anterior circulation AIS patients with a National Institute of Health Stroke Scale (NIHSS) score > 7 presenting within 8 h of symptom onset with endovascular treatment. All patients had non-contrast CT, CT angiography, and CTP. The neuro-interventionalist was blinded to the results of the CTP and based the treatment decision using the Alberta Stroke Program Early CT score (ASPECTS). Baseline demographics, co-morbidities, and baseline NIHSS scores were collected. Outcomes were modified Rankin scale (mRS) score at discharge and in-hospital mortality. Good outcomes were defined as a mRS score of 0–2. Results: 283 AIS patients were screened for the trial, and 119 were enrolled. The remaining patients were excluded for: posterior circulation stroke, no CTP performed, could not obtain consent, and NIHSS score < 7. Mean NIHSS score at admission was 16.8 ± 3, and mean ASPECTS was 8.4 ± 1.4. There was no statistically significant correlation with CTP penumbra and good outcomes: 50 versus 47.8% with no penumbra present (p = 0.85). In patients without evidence of CTP penumbra, there was 22.5% mortality compared to 22.1% mortality in patients with a CTP penumbra. If ASPECTS ≥7, 64.6% had good outcome versus 13.3% if ASPECTS < 7 (p < 0.001). Patients with an ASPECTS ≥7 had 10% mortality versus 51.4% in patients with an ASPECTS < 7 (p < 0.001). Conclusions: CTP penumbra did not identify patients who would benefit from endovascular treatment when patients were selected with non-contrast CT ASPECTS ≥7. There is no correlation of CTP penumbra with good outcomes or mortality. Larger prospective trials are warranted to justify the use of CTP within 6 h of symptom onset.

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Automated CT Perfusion Imaging Versus Non-contrast CT for Ischemic Core Assessment in Large Vessel Occlusion

Clinical Neuroradiology ◽

10.1007/s00062-018-0745-6 ◽

2018 ◽

Vol 30 (1) ◽

pp. 109-114 ◽

Cited By ~ 4

Author(s):

Anderson Chun On Tsang ◽

Stephanie Lenck ◽

Christopher Hilditch ◽

Patrick Nicholson ◽

Waleed Brinjikji ◽

...

Keyword(s):

Perfusion Imaging ◽

Ct Perfusion ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Vessel Occlusion ◽

Ct Perfusion Imaging ◽

Ischemic Core ◽

Contrast Ct

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Abstract WP19: Reliability of CT Perfusion in the Posterior Circulation in Comparison to the Anterior Circulation

Stroke ◽

10.1161/str.51.suppl_1.wp19 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Srijan Adhikari ◽

Justin Moore ◽

Abid Y Qureshi

Keyword(s):

Ct Perfusion ◽

Infarct Volume ◽

Posterior Circulation ◽

Large Vessel ◽

Anterior Circulation ◽

Kendall’S Tau ◽

Mean Velocity ◽

Vessel Occlusion ◽

Kendall's Tau ◽

Nonparametric Correlation

Background: DAWN and DEFUSE-3 excluded posterior-circulation cases, but in practice endovascular therapy (EVT) is common due to life-threatening large-vessel occlusions. Often CT perfusion (CTP) is acquired to aid in the decision-making of these cases, but the reliability of using CT perfusion in the posterior-circulation is unknown Hypothesis: Given the differences in hemodynamics (~20% of total CBF to the basilar, reduced mean velocity, and differences in collateral supply) penumbra estimates using RAPID software will be less accurate in predicting the final infarct volume on DWI. Methods: In patients who did not receive any treatment (tPA or EVT), the Tmax >6s, as operationally defined as penumbra, should approximate the infarct on DWI. As such, only posterior circulation patients without EVT or tPA were included. Anterior circulation patients were matched on demographics, medical history, outcomes. A ratio of Tmax/DWI was calculated to assess how closely perfusion approximated final infarct folume. Nonparametric correlation with Kendall’s tau-b was also performed. Results: Eleven patients with a posterior circulation large-vessel occlusion (pc-LVO) were compared to 30-matched patients with anterior circulation (ac-LVO). Age was 62.4±16 for ac-LVO vs. 64.5±13 for pc-LVO. Significant differences were seen in sex with ac-LVO 82% male, and pc-LVO 46% male (t=-2.06 p=0.046). Pc-LVO also had more subjects with an unknown last known well. Mean admission NIHSS was 15.6±8 ac-LVO, and 16.4±10 in pc-LVO group was similar. Mean discharge NIHSS was 12.6±9 ac-LVO vs 12.4±10 pc-LVO. NO signficicant difference in 30d mRS, 24h NIHSS, or mortality within 90d. As excpected in the anterior circulation cases final infarct volume correlated with Tmax>6s Kendall’s tau-b=0.57 (p=0.000013), and Tmax>8s (tau-b=0.55), Tmax>10s (tau-b=0.55. Whereas, In the posterior circulation Tmax>6s (tau-b=0.41, N.S.), but Tmax>8s (tau-b=0.64, p=0.007) and Tmax>10(tau-b=0.69, p=0.005). Seen another way the ratio of Tmax>6s:DWI = 2.47 (ac-LVO) vs 5.84 (pc-LVO) (t=-1.22, p=0.004, but Tmax>8s 1.57 vs 1.50 (t=0.11, p=9.12). Conclusion: Final infarct volume was not significantly associated with Tmax>6s in posterior circulation cases. Instead Tmax>8s is more reliable.

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Abstract WP129: MRI and Non Contrast CT Clot Imaging for Successful Large Vessel Clot Resolution of Posterior Circulation Ischemic Strokes

Stroke ◽

10.1161/str.48.suppl_1.wp129 ◽

2017 ◽

Vol 48 (suppl_1) ◽

Author(s):

Siddhart Mehta ◽

Spozhmy Panezai ◽

Ashish Kulhari ◽

Audrey Z Arango ◽

Laura Suhan ◽

...

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Endovascular Therapy ◽

Posterior Circulation ◽

Large Vessel ◽

Vessel Occlusion ◽

Imaging Characteristics ◽

Ct Angiogram ◽

Ct Head ◽

Contrast Ct

Background: Thrombi retrieved from patients with an acute ischemic stroke with Large Vessel Occlusion (LVO) and correlation with hyperdense vessel sign seen on non contrast CT and blooming artifact seen on gradient-echo(GRE) MRI have given relevant insights into the pathophysiology of thrombotic lesions (RBC-dominant vs Fibrin-dominant). This may facilitate the development of safer noninvasive reperfusion treatment approaches. Our goal was to evaluate the benefit of anticoagulation for posterior circulation strokes based on imaging characteristics in patients where endovascular therapy was not justified. Method: Comprehensive prospective evaluation of patients who presented with posterior circulation LVOs at a community based, university affiliated comprehensive stroke center during one year period (January 2015-December 2015) was done. The clot characteristics on thin-sliced reformatted CT, CT Angiogram and GRE MRI were noted. The clot size and characteristics were followed by sequential imaging while the patients were on anticoagulation for presumed embolic thrombus. Results: Total 749 patients presented with acute ischemic stroke during the pre-specified time period. Of those 78 were posterior circulation strokes; of which, 7 had LVO and 4 underwent endovascular treatment. Endovascular therapy was not justified in 3 patients due to clinically stable exam. These patients were thought to have embolic etiology of stroke and therefore were started on anticoagulation. Group A (RBC-dominant thrombus; n=2) mean clot length was 15.5mm, measured on CT, CTA, MRI. GRE MRI showed blooming artifact around the area of thrombus. Thrombus resolved on repeat CTA at 48-72hours. Group B (Fibrin-dominant; n=1) 5.5mm clot was visualized only on CTA (nothing on CT head and MRI) and it persisted on repeat CTA at 48-72hours. Mean initial NIHSS was 2 (SD +/- 1 ). Mean discharge NIHSS was 0.33 (SD +/- 0.577). Mean discharge mRS was 0.67 (SD +/- 0.57). Conclusion: Hyperdense sign on reformatted thin-sliced CT head and blooming artifact on GRE MRI brain in patients with LVO can be used to characterize the composition of thrombus, which could be helpful in deciding medical therapy. A larger prospective randomized trial is needed to corroborate our findings.

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Abstract 60: Impact of Monthly Testing and Tutorials on Accuracy and Confidence of Telestroke Nurse Recognition of Anterior Circulation Large Vessel Occlusion CT Perfusion Patterns

Stroke ◽

10.1161/str.51.suppl_1.60 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Emily K Snider ◽

Brenda Chang ◽

Anna Maria Helms ◽

Laura Williams ◽

Sam Singh ◽

...

Keyword(s):

Good Accuracy ◽

Internal Carotid ◽

Ct Perfusion ◽

Large Vessel ◽

Large Vessel Occlusion ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Confidence Levels ◽

Lower Confidence ◽

The Impact

Introduction: A distinguishing feature of our Stroke Network is Telestroke (TS) nurses (RNs) who remotely facilitate TS evaluations. To facilitate expeditious transfer the TS RNs, need to immediately identify CT perfusion (CTP) studies demonstrating patterns consistent with internal carotid artery (ICA), middle cerebral artery (M1), and first branch of the M1 (M2) large vessel occlusion (LVO) acute ischemic strokes (AIS). Methods: We developed a 6-month series of tutorials and tests (12 CTP scans/month) for 16 TS RNs to recognize CTP patterns consistent with ICA, M1 or M2 LVO AIS. We simultaneously conducted a prospective cohort study of these nurses on the impact of these tutorials and tests. Results: TS nurses demonstrated good accuracy in detecting ICA, M1 or M2 LVO presence during the first three months of teaching (83-94% accurate).This improved to excellent during the last three months (99-100%), during which the likelihood of correctly identifying the presence of any one of these LVOs was greater than in the first three months (OR 1.99, 95% CI: 1.83-2.17, p<0.001). The probability of correctly identifying ICA or M1 occlusions was much higher than correctly identifying all other LVOs (OR 68, 95% CI: 45-102, p<0.001). The likelihood of being at a higher confidence level compared to lower confidence levels in identifying any LVOs as being ICA or M1 was higher than in identifying other LVOs (OR 2.14, 95% CI: 1.6-2.8, p<0.001), but over time confidence for determining LVO presence did not differ significantly after controlling for subject variation. Conclusion: A series of structured tutorials significantly increased the odds of TS nurses correctly identifying anterior circulation LVOs, with the benefit of these tutorials and test reviews peaking and plateauing at four months. Participating in TS nurse tutorials was associated with high odds and confidence for correctly identifying LVOs as being ICA or M1.

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A population-based incidence of M2 strokes indicates potential expansion of large vessel occlusions amenable to endovascular therapy

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2017-013371 ◽

2017 ◽

Vol 10 (6) ◽

pp. 510-515 ◽

Cited By ~ 31

Author(s):

Ansaar T Rai ◽

Jennifer R Domico ◽

Chelsea Buseman ◽

Abdul R Tarabishy ◽

Daniel Fulks ◽

...

Keyword(s):

Endovascular Therapy ◽

Infarct Volume ◽

Area Under The Curve ◽

Recombinant Tissue Plasminogen Activator ◽

Large Vessel ◽

Neurological Deficits ◽

Operating Characteristics ◽

Vessel Occlusion ◽

Nihss Score ◽

Poor Outcomes

BackgroundM2 occlusions may result in poor outcomes and potentially benefit from endovascular therapy. Data on the rate of M2 strokes is lacking.MethodologyPatients with acute ischemic stroke discharged over a period of 3 years from a tertiary level hospital in the ‘stroke belt’ were evaluated for M2 occlusions on baseline vascular imaging. Regional and national incidence was calculated from discharge and multicounty data.ResultsThere were 2739 ICD-9 based AIS discharges. M2 occlusions in 116 (4%, 95% CI 3.5% to 5%) patients constituted the second most common occlusion site. The median National Institute of Health Stroke Scale (NIHSS) score was 12 (IQR 5–18). Good outcomes were observed in 43% (95% CI 34% to 53%), poor outcomes in 57% (95% CI 47% to 66%), and death occurred in 27% (95% CI 19% to 37%) of patients. Receiver operating characteristics curves showed the NIHSS to be predictive of outcomes (area under the curve 0.829, 95% CI 0.745 to 0.913, p<0.0001). An NIHSS score ≥9 was the optimal cut-off point for predicting poor outcomes (sensitivity 85.7%, specificity 67.4%). 71 (61%) patients had an NIHSS score ≥9 and 45 (39%) an NIHSS score <9. The rate of good-outcome was 22.6% for NIHSS score ≥9 versus 78.4% for NIHSSscore <9 (OR=0.08, 95% CI 0.03 to 0.21, p<0.0001). Mortality was 42% for NIHSS score ≥9 versus 2.7% for NIHSS score <9 (OR=26, 95% CI 3.3 to 202, p<0.0001). Infarct volume was 57 (±55.7) cm3 for NIHSS score ≥9 versus 30 (±34)cm3 for NIHSS score <9 (p=0.003). IV recombinant tissue plasminogen activator (rtPA) administered in 28 (24%) patients did not affect outcomes. The rate of M2 occlusions was 7 (95% CI 5 to 9)/100 000 people/year (3%, 95% CI 2% to 4%), giving an incidence of 21 176 (95% CI 15 282 to 29 247)/year. Combined with M1, internal carotid artery terminus and basilar artery, this yields a ‘large vessel occlusion (LVO)+M2’ rate of 31 (95% CI 26 to 35)/100 000 people/year and a national incidence of 99 227 (95% CI 84 004 to 112 005) LVO+M2 strokes/year.ConclusionM2 occlusions can present with serious neurological deficits and cause significant morbidity and mortality. Patients with M2 occlusions and higher baseline deficits (NIHSS score ≥9) may benefit from endovascular therapy, thus potentially expanding the category of acute ischemic strokes amenable to intervention.

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