Abstract 31: Penumbra Consumption Rates Based on T Max Delay and Reperfusion Status: A Post-Hoc Analysis of the Defuse-3 Trial

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shadi Yaghi ◽  
Eytan Raz ◽  
Seena Dehkharghani ◽  
Howard Riina ◽  
Ryan McTaggart ◽  
...  
Keyword(s):  
Infarct Volume ◽  
Secondary Analysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Consumption Rates ◽  
Definition Of ◽  
Post Hoc ◽  
New Generation

Introduction: In patients with acute large vessel occlusion, the definition of penumbral tissue based on T max delay perfusion imaging is not well established in relation to late-window endovascular thrombectomy (EVT). In this study, we sought to evaluate penumbra consumption rates for T max delays in patients treated between 6 and 16 hours from last known normal. Methods: This is a secondary analysis of the DEFUSE-3 trial, which included patients with an acute ischemic stroke due to anterior circulation occlusion within 6-16 hours of last known normal. The primary outcome is percentage penumbra consumption defined as (24 hour infarct volume-core infarct volume)/(Tmax volume-baseline core volume). We stratified the cohort into 4 categories (untreated, TICI 0-2a, TICI 2b, and TICI3) and calculated penumbral consumption rates. Results: We included 143 patients, of which 66 were untreated, 16 had TICI 0-2a, 46 had TICI 2b, and 15 had TICI 3. In untreated patients, a median (IQR) of 48% (21% - 85%) of penumbral tissue was consumed based on Tmax6 as opposed to 160.6% (51% - 455.2%) of penumbral tissue based on Tmax10. On the contrary, in patients achieving TICI 3 reperfusion, a median (IQR) of 5.3% (1.1% - 14.6%) of penumbral tissue was consumed based on Tmax6 and 25.7% (3.2% - 72.1%) of penumbral tissue based on Tmax10. Conclusion: Contrary to prior studies, we show that at least 75% of penumbral tissue with Tmax > 10 sec delay can be salvaged with successful reperfusion and new generation devices. In untreated patients, since infarct expansion can occur beyond 24 hours, future studies with delayed brain imaging are needed to determine the optimal T max delay threshold that defines penumbral tissue in patients with proximal anterior circulation large vessel occlusion.

Penumbra Consumption Rates Based on Time-to-Maximum Delay and Reperfusion Status: A Post Hoc Analysis of the DEFUSE 3 Trial

Stroke ◽  
2021 ◽  
Author(s):  
Shadi Yaghi ◽  
Eytan Raz ◽  
Seena Dehkharghani ◽  
Howard Riina ◽  
Ryan McTaggart ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Infarct Volume ◽  
Interquartile Range ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Post Hoc Analysis ◽  
Consumption Rates ◽  
Post Hoc

Background and Purpose: In patients with acute large vessel occlusion, the natural history of penumbral tissue based on perfusion time-to-maximum (T max ) delay is not well established in relation to late-window endovascular thrombectomy. In this study, we sought to evaluate penumbra consumption rates for T max delays in patients with large vessel occlusion evaluated between 6 and 16 hours from last known normal. Methods: This is a post hoc analysis of the DEFUSE 3 trial (The Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke), which included patients with an acute ischemic stroke due to anterior circulation occlusion within 6 to 16 hours of last known normal. The primary outcome is percentage penumbra consumption, defined as (24-hour magnetic resonance imaging infarct volume–baseline core infarct volume)/(T max 6 or 10 s volume–baseline core volume). We stratified the cohort into 4 categories based on treatment modality and Thrombolysis in Cerebral Infarction (TICI score; untreated, TICI 0-2a, TICI 2b, and TICI3) and calculated penumbral consumption rates in each category. Results: We included 141 patients, among whom 68 were untreated. In the untreated versus TICI 3 patients, a median (interquartile range) of 53.7% (21.2%–87.7%) versus 5.3% (1.1%–14.6%) of penumbral tissue was consumed based on T max >6 s ( P <0.001). In the same comparison for T max >10 s, we saw a difference of 165.4% (interquartile range, 56.1%–479.8%) versus 25.7% (interquartile range, 3.2%–72.1%; P <0.001). Significant differences were not demonstrated between untreated and TICI 0-2a patients for penumbral consumption based on T max >6 s ( P =0.52) or T max >10 s ( P =0.92). Conclusions: Among extended window endovascular thrombectomy patients, T max >10-s mismatch volume may comprise large volumes of salvageable tissue, whereas nearly half the T max >6-s mismatch volume may remain viable in untreated patients at 24 hours.

Abstract P513: Effect of Premorbid Antiplatelet Medication on Infarct Volume at 24 Hours After Late Window Presentation With Anterior Circulation Large Vessel Occlusion

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Adam H de Havenon ◽  
Soren Christensen ◽  
Maarten G Lansberg ◽  
Michael Mlynash ◽  
Gregory W Albers ◽  
...  
Keyword(s):  
Sensitivity Analysis ◽  
Infarct Volume ◽  
Secondary Analysis ◽  
Large Vessel ◽  
Clot Lysis ◽  
Linear Regression Models ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Antiplatelet Medication

Introduction: We sought to evaluate the effect of premorbid antiplatelet medication on 24 hour infarct volume in late presenting patients with anterior circulation large vessel occlusion. Methods: This is a secondary analysis of the DEFUSE 3 trial. The primary outcome is infarct volume on a 24-hour MRI scan (volume of DWI positive tissue). The primary predictor is premorbid use of an antiplatelet medication. We fit linear regression models to 24-hour infarct volume and adjusted for admission infarct volume, age, sex, treatment arm, anticoagulant use, time from stroke onset to presentation, hypoperfusion intensity ratio, tPA administration, admission NIH Stroke Scale, glucose, and systolic blood pressure. In a sensitivity analysis, we included recanalization status in the model (no vs. partial vs. complete recanalization). All models had variance inflation factors <2, indicating acceptable multicollinearity. Results: We included 149 patients, of which 51 (34.2%) took premorbid antiplatelet medication. The mean±SD 24-hour infarct volume was 51.7±50.1 in antiplatelet versus 80.4±93.6 ml in control patients (p=0.04). In the adjusted regression model, taking an antiplatelet medication had a beta coefficient of -31.2 (95% CI, -55.0, -7.4; p=0.011). The other significant predictors of 24-hour infarct volume were admission glucose, baseline infarct volume, and HIR. In the sensitivity analysis with recanalization status in the model (n=132), premorbid antiplatelet use remained associated with 24-hour infarct volume (beta=-29.6, 95% CI -55.8, -3.4, p=0.027). Conclusion: For patients with late window anterior circulation large vessel occlusion stroke, premorbid use of an antiplatelet medication was associated with a ~30 mL smaller 24-hour infarct volume on MRI. Possible explanations for this finding include reduced clot burden, improved clot lysis, the anti-inflammatory effects of antiplatelet medications, or the results could be due to chance.

Abstract P505: Prediction of Infarct Volume at the 24 Hours After Late Window Presentation With Perfusion Imaging in Patients With Anterior Circulation Large Vessel Occlusion

Stroke ◽  
2021 ◽  
Vol 52 (Suppl_1) ◽  
Author(s):  
Shashank Agarwal ◽  
Eytan Raz ◽  
Seena Dehkharghani ◽  
Soren Christensen ◽  
Marteen G Lansberg ◽  
...  
Keyword(s):  
Perfusion Imaging ◽  
Infarct Volume ◽  
Secondary Analysis ◽  
Large Vessel ◽  
Linear Regression Models ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Volume Table

Introduction: We sought to evaluate the accuracy of perfusion-weighted imaging (PWI) in late presenting patients for estimating the infarct volume at 24 hours after presentation. Methods: This is a secondary analysis of DEFUSE 3, which included stroke patients with anterior circulation occlusion within 6-16 hours of last known normal. The primary outcome is the final infarct volume on a 24-hour MRI scan (volume of DWI positive tissue), adjusted for the baseline infarct volume. We censored 3 patients with 24-hour follow-up MRI infarct volumes >300 mL, which we considered non-physiologic for a hemispheric stroke. The primary predictors are the baseline volume of Tmax >6s, Tmax >10s, and hypoperfusion intensity ratio (HIR: Tmax10/Tmax6) on CT/MR perfusion at hospital admission. We stratified the cohort into 4 categories (untreated, TICI 0-2a, TICI 2b, and TICI3) and fit linear regression models to each of our predictors. Results: We included 147 patients, of which 69 were untreated, 17 had TICI 0-2a, 46 had TICI 2b, and 15 had TICI 3. In untreated patients, both HIR and Tmax10 volume were predictive of adjusted 24-hour follow-up infarct volume (Table). In treated patients, there were no consistent relationships between the perfusion imaging variables and adjusted final infarct volume (Table). Conclusion: For patients with late window anterior circulation large vessel occlusion stroke, HIR and Tmax10 volume appear to be reliable predictors of subsequent infarct volume in untreated patients. For patients treated with thrombectomy, further research is warranted to better understand the more complex relationship between baseline perfusion imaging and the 24 hour, and beyond, infarct volume.

Abstract TP74: Aspects Scoring Applied to CTA Source Images is Predictive of Final Infarct Volume and Good Functional Outcome

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Joseph F Carrera ◽  
Joseph H Donahue ◽  
Prem P Batchala ◽  
Andrew M Southerland ◽  
Bradford B Worrall
Keyword(s):  
Linear Regression ◽  
Functional Outcome ◽  
Infarct Volume ◽  
Univariate Analysis ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome ◽  
The Impact

Introduction: CTP and MRI are increasingly used to assess endovascular thrombectomy (EVT) candidacy in large vessel occlusion stroke. Unfortunately, availability of these advanced neuroimaging techniques is not widespread and this can lead to over-triage to EVT-capable centers. Hypothesis: ASPECTS scoring applied to computed tomography angiography source images (CTA-SI) will be predictive of final infarct volume (FIV) and functional outcome. Methods: We reviewed data from consecutive patients undergoing EVT at our institution for anterior circulation occlusion between 01/14 - 01/19. We recorded demographics, comorbidities, NIHSS, treatment time parameters, and outcomes as defined by mRS (0-2 = good outcome). Cerebrovascular images were assessed by outcome-blinded raters and collateral score, TICI score, FIV, and both CT and CTA-SI ASPECTS scores were noted. Patients were grouped by ASPECTS score into low (0-4), intermediate (5-7), and high (8-10) for some analyses. FIV was predicted using a linear regression with NIHSS, good reperfusion (TICI 2b/3), collateral score, CT to groin puncture, CT and CTA-SI ASPECTS as independent variables. After excluding those with baseline mRS≥2, a binary logistic regression was performed including covariates of age, NIHSS, good reperfusion, and diabetes (factors significant at p<0.05 on univariate analysis) to assess the impact of CTA-SI ASPECTS group on outcome. Results: Analysis included 137 patients for FIV and 102 for outcome analysis (35 excluded for baseline mRS≥ 2). Linear regression found CTA-SI ASPECTS (Beta -10.8, p=0.002), collateral score (Beta -42.9, p=0.001) and good reperfusion (Beta 72.605, p=0.000) were independent predictors of FIV. Relative to the low CTA-SI ASPECTS group, the high CTA-SI ASPECTS group was more likely to have good outcome (OR 3.75 [95% CI 1.05-13.3]; p=0.41). CT ASPECTS was not predictive of FIV or good outcome. Outcomes: In those undergoing EVT for anterior circulation occlusion, CTA-SI ASPECTS is predictive of both FIV and functional outcome, while CT ASPECTS predicts neither. CTA-SI ASPECTS holds promise as a lower-cost, more widely available option for triage of patients with large vessel occlusion. Further study is needed comparing CTA-SI ASPECTS to CTP parameters.

Abstract 132: Final Infarct Volume is a Critical Determinant of Hospitalization Cost in Anterior Circulation Large Vessel Occlusion Stroke

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Christopher Streib ◽  
Srikant Rangaraju ◽  
Daniel G Winger ◽  
David T Campbell ◽  
Stephanie Paolini ◽  
...  
Keyword(s):  
Infarct Volume ◽  
Cost Effective ◽  
Large Vessel ◽  
Sensitivity Analyses ◽  
Large Vessel Occlusion ◽  
Primary Analysis ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Critical Determinant ◽  
Hospitalization Cost

Background: Anterior circulation large vessel occlusion (ACLVO) stroke, one of the most devastating stroke subtypes, is associated with substantial economic burden. Identifying predictors of increased ACLVO stroke hospitalization cost is essential to developing cost-effective treatment strategies. Methods: We utilized comprehensive patient-level cost-tracking software to calculate hospitalization costs for ACLVO stroke patients at our institution between July 2012-October 2014. Patient demographics and neuroimaging findings were analyzed. Predictors of hospitalization cost were determined using multivariable linear regression. In addition to our primary analysis (all eligible ACLVO patients), we conducted subgroup analyses by treatment (endovascular, IV tPA-only, and no reperfusion therapy) and sensitivity analyses. Results: 341 patients (median age 69 [IQR 57-80], median NIHSS 16 [IQR 13-21], median hospitalization cost $16,446 [IQR $9823-$27,165]) were included in our primary analysis; final infarct volume (FIV), parenchymal hematoma, age, obstructive sleep apnea, and baseline NIHSS were significant predictors of hospitalization cost (Figure). FIV alone accounted for 20.51% of the total variance in hospitalization cost. Notably, FIV was consistently the most robust predictor of increased cost across primary, subgroup, and sensitivity analyses. Over the observed range of FIVs in our cohort, each additional 1cc of infarcted brain tissue increased hospitalization cost by $122.35. Conclusion: FIV is a critical determinant of increased hospitalization cost in ACLVO stroke. Therapies resulting in reduced FIV may not only improve clinical outcomes, but prove cost-effective.

scholarly journals Infarct Volume Predicts Hospitalization Costs in Anterior Circulation Large-Vessel Occlusion Stroke

2018 ◽  
Vol 40 (1) ◽  
pp. 51-58 ◽  
Author(s):  
C.D. Streib ◽  
S. Rangaraju ◽  
D.T. Campbell ◽  
D.G. Winger ◽  
S.L. Paolini ◽  
...  
Keyword(s):  
Infarct Volume ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Hospitalization Costs

Intravenous alteplase has different effects on the efficacy of aspiration and stent retriever thrombectomy: analysis of the COMPASS trial

2021 ◽  
pp. neurintsurg-2021-017943
Author(s):  
Maxim Mokin ◽  
Muhammad Waqas ◽  
Johanna T Fifi ◽  
Reade De Leacy ◽  
David Fiorella ◽  
...  
Keyword(s):  
Univariate Analysis ◽  
Stent Retriever ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Aspiration Thrombectomy ◽  
Conflicting Evidence ◽  
Intravenous Alteplase ◽  
Post Hoc

BackgroundThere is conflicting evidence on the utility of intravenous (IV) alteplase in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT).MethodsThis was a post hoc analysis of the COMPASS: a trial of aspiration thrombectomy versus stent retriever thrombectomy as first-line approach for large vessel occlusion. We compared clinical, procedural and angiographic outcomes of patients with and without prior IV alteplase administration.ResultsIn the COMPASS trial, 235 patients had presented to the hospital within the first 4 hours of stroke symptom onset and were eligible for analysis. On univariate analysis, administration of IV alteplase prior to MT was found to be significantly associated with favorable outcomes (modified Rankin scale (mRS) 0–2 at 3 months; 55.6% vs 40.0% in the MT-only group, P=0.037). However, on multivariate analysis, only baseline (pre-stroke) mRS, admission National Institutes of Health Stroke Scale (NIHSS) score and age were identified as independent predictors of favorable outcomes at 3 months. We found higher final thrombolysis in cerebral infarction (TICI) 2b/3 rates in patients without the use of alteplase prior to the aspiration first approach (100.0% vs 87.9% in IV altepase +aspiration first MT, P=0.03). In the stent retriever first group, final TICI 2b/3 rates were identical in patients with and without IV alteplase administration (87.5% and 87.5%, P=1.0).ConclusionsPrior administration of IV alteplase may adversely affect the efficacy of aspiration, but does not seem to influence the stent retriever first approach to MT in patients with anterior circulation ELVO.

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