Burden of large vessel occlusion stroke and the service gap of thrombectomy: A population-based study using a territory-wide public hospital system registry

2019 ◽  
Vol 15 (1) ◽  
pp. 69-74 ◽  
Author(s):  
Anderson C.O. Tsang ◽  
Jia You ◽  
Lai Fung Li ◽  
Frederick C.P. Tsang ◽  
Pauline P.S. Woo ◽  
...  
Keyword(s):  
Hong Kong ◽  
Ischemic Stroke ◽  
Population Based ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
The Public ◽  
Service Gap

Background Ischemic stroke due to large vessel occlusion can be effectively treated with thrombectomy but access to this treatment is limited in many parts of the world. Local incidence of large vessel occlusion is critical in determining the development of thrombectomy service, but reliable data from Asian countries are lacking. Aims We performed a population-based study to estimate the burden of large vessel occlusion and the service gap for thrombectomy in Hong Kong. Methods All acute ischemic stroke patients admitted in 2016 to the public healthcare system, which provided 90% of the emergency healthcare in the city, was identified from the Hong Kong Hospital Authority’s central electronic database. The diagnosis of large vessel occlusion was retrospectively verified by two independent cerebrovascular specialists in a randomly sampled cohort based on clinical and neuroimaging data. The incidence of large vessel occlusion in the population was estimated through weighting the sample results and compared with the thrombectomy data in the same period. Results There were 6859 acute ischemic stroke patients treated in the public health system in 2016. Amongst the 300 patients randomly sampled according to diagnosis coding, 130 suffered from anterior circulation large vessel occlusion. This translated to 918 patients (95% CI 653–1180) and 13.3% of all ischemic stroke patients. The estimated incidence of anterior circulation large vessel occlusion was 12.5 per 100,000 persons per year (95% CI 11.7–13.4). Large vessel occlusion stroke patients were more commonly female than male (67.4% vs. 31.6%, p = 0.003), and were older than non-large vessel occlusion stroke patients (mean of 80.5 years vs. 71.4 years, p = < 0.001). They also had higher 30-day mortality rate (31.1% vs. 4.6%, p = < 0.001), and longer hospital stay (mean 38.6 vs. 21.1 days, p = 0.003) than non-large vessel occlusion stroke. In the same period, 83 thrombectomies for large vessel occlusion were performed, representing 9.1% of the estimated large vessel occlusion incidence. Conclusion The estimated incidence of anterior circulation large vessel occlusion in the Hong Kong Chinese population is lower than that in the West. There is however a substantial service gap for endovascular thrombectomy with less than 10% of large vessel occlusion patients receiving thrombectomy.

scholarly journals Factors associated with prominent vessel sign on susceptibility-weighted imaging in acute ischemic stroke

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Hai-fei Jiang ◽  
Yi-qun Zhang ◽  
Jiang-xia Pang ◽  
Pei-ning Shao ◽  
Han-cheng Qiu ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Large Vessel ◽  
Susceptibility Weighted Imaging ◽  
Regression Analyses ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Factors Associated ◽  
Univariate Analyses

AbstractThe prominent vessel sign (PVS) on susceptibility-weighted imaging (SWI) is not displayed in all cases of acute ischemia. We aimed to investigate the factors associated with the presence of PVS in stroke patients. Consecutive ischemic stroke patients admitted within 24 h from symptom onset underwent emergency multimodal MRI at admission. Associated factors for the presence of PVS were analyzed using univariate analyses and multivariable logistic regression analyses. A total of 218 patients were enrolled. The occurrence rate of PVS was 55.5%. Univariate analyses showed significant differences between PVS-positive group and PVS-negative group in age, history of coronary heart disease, baseline NIHSS scores, total cholesterol, hemoglobin, anterior circulation infarct, large vessel occlusion, and cardioembolism. Multivariable logistic regression analyses revealed that the independent factors associated with PVS were anterior circulation infarct (odds ratio [OR] 13.7; 95% confidence interval [CI] 3.5–53.3), large vessel occlusion (OR 123.3; 95% CI 33.7–451.5), and cardioembolism (OR 5.6; 95% CI 2.1–15.3). Anterior circulation infarct, large vessel occlusion, and cardioembolism are independently associated with the presence of PVS on SWI.

Prestroke Disability and Outcome After Thrombectomy for Emergent Anterior Circulation Large Vessel Occlusion Stroke

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000012827
Author(s):  
Adam de Havenon ◽  
Alicia Castonguay ◽  
Raul Nogueira ◽  
Thanh N. Nguyen ◽  
Joey English ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Ischemic Stroke ◽  
Odds Ratio ◽  
Adjusted Odds Ratio ◽  
Primary Outcome ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion

ObjectiveTo determine the impact of endovascular therapy for large vessel occlusion stroke in patients with pre-morbid disability versus those without.MethodsWe performed a post-hoc analysis of the TREVO Stent-Retriever Acute Stroke (TRACK) Registry, which collected data on 634 consecutive stroke patients treated with the Trevo device as first-line EVT at 23 centers in the United States. We included patients with internal carotid or middle cerebral (M1/M2 segment) artery occlusions and the study exposure was patient- or caregiver-reported premorbid modified Rank Scale (mRS) ≥2 (premorbid disability, PD) versus premorbid mRS score 0-1 (no premorbid disability, NPD). The primary outcome was no accumulated disability, defined as no increase in 90-day mRS from the patient’s pre-morbid mRS.ResultsOf the 634 patients in TRACK, 407 patients were included in our cohort, of which 53/407 (13.0%) had PD. The primary outcome of no accumulated disability was achieved in 37.7% (20/53) of patients with PD and 16.7% (59/354) of patients with NPD (p<0.001), while death occurred in 39.6% (21/53) and 14.1% (50/354) (p<0.001), respectively. The adjusted odds ratio of no accumulated disability for PD patients was 5.2 (95% CI 2.4-11.4, p<0.001) compared to patients with NPD. However, the adjusted odds ratio for death in PD patients was 2.90 (95% CI 1.38-6.09, p=0.005).ConclusionsIn this study of anterior circulation acute ischemic stroke patients treated with EVT, we found that premorbid disability was associated with a higher probability of not accumulating further disability compared to patients with no premorbid disability, but also with higher probability of death.Classification of EvidenceThis study provides Class II evidence that in anterior circulation acute ischemic stroke treated with EVT, patients with premorbid disability compared to those without disability were more likely not to accumulate more disability but were more likely to die.


Abstract 151: Early Neurologic Decline in Acute Ischemic Stroke Patients Receiving Thrombolysis With Large Vessel Occlusion and Initial Mild Deficits

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Gaurav Thakur ◽  
Ciaran J Powers ◽  
Shahid M Nimjee ◽  
Patrick Youssef ◽  
Sushil Lakhani ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Natural History ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Intravenous Tissue Plasminogen Activator ◽  
The Mean

Introduction: A quarter of ischemic stroke patients with initial mild deficits have a poor outcome. We sought to determine the rate of early neurological decline in acute ischemic stroke patients with large vessel occlusion (LVO) who presented with mild deficits. Methods: Among 1022 acute ischemic stroke patients who received intravenous tissue plasminogen activator (IVtPA) admitted to our institution from January 1, 2014 to March 31, 2019, we identified 313 (30.6%) with LVO. We defined anterior circulation LVO as M1, M2, or carotid artery terminus (ICAT). Mild deficits were defined as National Institute of Health Stroke Scale (NIHSS) ≤ 7. Data was abstracted on demographics, neuroimaging, last known well (LKW), time to IVtPA, intra-arterial therapy (IAT) revascularization, Thrombolysis in Cerebral Infarction score (TICI), clinical presentation, and outcome. Early neurologic decline was defined as NIHSS worsening of ≥ 4 points within 24 hours. Results: Among 313 patients with LVO, we identified 94 (30%) who presented with initial low NIHSS (≤ 7) due to anterior circulation LVO. We excluded 13 patients who did not have natural history data (underwent IAT with mild deficits), leaving 81 patient for analysis. The mean age was 65.8 years (range 25 to 93) and 41% were female. IVtPA time from LKW was a mean 2.5 hours (range, 0.8 to 7). LVO sites were as follows: 5 (6%) ICAT, 23 (28%) M1, and 53 (65%) M2 occlusions. Among the 81 patients, 27 (33.3%) had early neurological decline. Patients with decline were significantly older (71.2 vs 63.1 years, p=0.03). Among the 27 patients with decline, the mean change in NIHSS was 10.5 (range, 4 to 22) and 12 patients (44%) underwent rescue IAT resulting in TICI 2B (6) and TICI 3 (6) revascularization. On hospital discharge, patients with decline were less likely to be discharged home (26% vs 65%, p=0.006). Conclusions: Among LVO patients who received IVtPA, 30% present with initial mild deficits. Early neurological decline occurred in one-third of LVO patients with initial mild deficits despite receiving IVtPA, and patients with decline were less likely to be discharged home. Clinicians need to be aware of the natural history of LVO with initial mid deficits, as patients who decline would be eligible for rescue IAT in the expanded 24 hour window.

Abstract WP39: Mechanical Embolectomy for Acute Ischemic Stroke Beyond Six Hours From Symptom Onset Using Advanced MR Imaging

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Ryan McTaggart ◽  
Shadi Yaghi ◽  
Daniel C Sacchetti ◽  
Richard Haas ◽  
Shawna Cutting ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Mr Imaging ◽  
Acute Ischemic Stroke ◽  
Large Vessel ◽  
Lesion Volume ◽  
Large Artery ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Good Outcome

Background: There is very limited data on the use of advanced neuroimaging to select patients with acute ischemic stroke and large vessel occlusion for intraarterial therapy beyond 6 hours from onset. Our aim is to report the outcome of patients with acute ischemic stroke and large artery occlusion who presented beyond 6 hours from onset, had favorable MRI imaging profile, and underwent mechanical embolectomy. Methods: This is a single institution retrospective study between December 1st, 2015, and July 30 th , 2016 with acute ischemic stroke and anterior circulation large vessel occlusion (LVO) with ASPECTS of 6 or more and beyond 6 hours from symptoms onset. Favorable imaging profile was defined as 1) DWI lesion volume (as defined as apparent diffusion coefficient < 620 X 10-6 mm2/s) of 70 mL or less AND 2) Penumbra volume (as defined by volume of tissue with Tmax >6 sec) of 15 mL or greater AND 3) A mismatch ratio of 1.8 or more AND 4) Volume of tissue with perfusion lesion with Tmax > 10 sec is less than 100 mL. Good outcome was defined as a 90 day mRS≤2. Results: In the study period, 41 patients met the inclusion criteria; 22 (53.6%) had favorable imaging profile and underwent mechanical embolectomy. The median age was 75 years (59-92), 68.2% were females; the median time from last known normal to groin puncture was 684.5 minutes (range 363-1628) and the median admission NIHSS score was 17.5 (range 4-28). The rate of good outcomes in this series was similar to that in a patient level pooled meta-analysis of the recent endovascular trials (68.2% vs. 46.0%, p=0.07). The rate of good outcome matches that of the EXTEND-IA trial that selected patients using perfusion imaging (68.2% vs. 71.0%, p = 1.00). None of the patients in our cohort had symptomatic intracereberal hemorrhage. Conclusion: Advanced MR imaging may help select patients with acute ischemic stroke and anterior circulation large vessel occlusion for embolectomy beyond the treatment window used in most endovascular trials.

scholarly journals Workflow Intervals of Endovascular Acute Stroke Therapy During On- Versus Off-Hours

Stroke ◽  
2019 ◽  
Vol 50 (10) ◽  
pp. 2842-2850 ◽  
Author(s):  
Wouter H. Hinsenveld ◽  
Inger R. de Ridder ◽  
Robert J. van Oostenbrugge ◽  
Jan A. Vos ◽  
Adrien E. Groot ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Endovascular Treatment ◽  
Acute Ischemic Stroke ◽  
Functional Outcome ◽  
Large Vessel ◽  
Complication Rates ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Significant Difference

Background and Purpose— Endovascular treatment (EVT) of patients with acute ischemic stroke because of large vessel occlusion involves complicated logistics, which may cause a delay in treatment initiation during off-hours. This might lead to a worse functional outcome. We compared workflow intervals between endovascular treatment–treated patients presenting during off- and on-hours. Methods— We retrospectively analyzed data from the MR CLEAN Registry, a prospective, multicenter, observational study in the Netherlands and included patients with an anterior circulation large vessel occlusion who presented between March 2014 and June 2016. Off-hours were defined as presentation on Monday to Friday between 17:00 and 08:00 hours, weekends (Friday 17:00 to Monday 8:00) and national holidays. Primary end point was first door to groin time. Secondary end points were functional outcome at 90 days (modified Rankin Scale) and workflow time intervals. We stratified for transfer status, adjusted for prognostic factors, and used linear and ordinal regression models. Results— We included 1488 patients of which 936 (62.9%) presented during off-hours. Median first door to groin time was 140 minutes (95% CI, 110–182) during off-hours and 121 minutes (95% CI, 85–157) during on-hours. Adjusted first door to groin time was 14.6 minutes (95% CI, 9.3–20.0) longer during off-hours. Door to needle times for intravenous therapy were slightly longer (3.5 minutes, 95% CI, 0.7–6.3) during off-hours. Groin puncture to reperfusion times did not differ between groups. For transferred patients, the delay within the intervention center was 5.0 minutes (95% CI, 0.5–9.6) longer. There was no significant difference in functional outcome between patients presenting during off- and on-hours (adjusted odds ratio, 0.92; 95% CI, 0.74–1.14). Reperfusion rates and complication rates were similar. Conclusions— Presentation during off-hours is associated with a slight delay in start of endovascular treatment in patients with acute ischemic stroke. This treatment delay did not translate into worse functional outcome or increased complication rates.

scholarly journals Mechanical Thrombectomy in Ischemic Stroke Patients With Alberta Stroke Program Early Computed Tomography Score 0–5

Stroke ◽  
2019 ◽  
Vol 50 (4) ◽  
pp. 880-888 ◽  
Author(s):  
Johannes Kaesmacher ◽  
Panagiotis Chaloulos-Iakovidis ◽  
Leonidas Panos ◽  
Pasquale Mordasini ◽  
Patrik Michel ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Intracerebral Hemorrhage ◽  
Mechanical Thrombectomy ◽  
Functional Independence ◽  
Favorable Outcome ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Symptomatic Intracerebral Hemorrhage

Background and Purpose— If anterior circulation large vessel occlusion acute ischemic stroke patients presenting with ASPECTS 0–5 (Alberta Stroke Program Early CT Score) should be treated with mechanical thrombectomy remains unclear. Purpose of this study was to report on the outcome of patients with ASPECTS 0–5 treated with mechanical thrombectomy and to provide data regarding the effect of successful reperfusion on clinical outcomes and safety measures in these patients. Methods— Multicenter, pooled analysis of 7 institutional prospective registries: Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy (Clinical Trial Registration—URL: https://www.clinicaltrials.gov . Unique identifier: NCT03496064). Primary outcome was defined as modified Rankin Scale 0–3 at day 90 (favorable outcome). Secondary outcomes included rates of day 90 modified Rankin Scale 0–2 (functional independence), day 90 mortality and occurrence of symptomatic intracerebral hemorrhage. Multivariable logistic regression analyses were performed to assess the association of successful reperfusion with clinical outcomes. Outputs are displayed as adjusted Odds Ratios (aOR) and 95% CI. Results— Two hundred thirty-seven of 2046 patients included in this registry presented with anterior circulation large vessel occlusion and ASPECTS 0–5. In this subgroup, the overall rates of favorable outcome and mortality at day 90 were 40.1% and 40.9%. Achieving successful reperfusion was independently associated with favorable outcome (aOR, 5.534; 95% CI, 2.363–12.961), functional independence (aOR, 5.583; 95% CI, 1.964–15.873), reduced mortality (aOR, 0.180; 95% CI, 0.083–0.390), and lower rates of symptomatic intracerebral hemorrhage (aOR, 0.235; 95% CI, 0.062–0.887). The mortality-reducing effect remained in patients with ASPECTS 0–4 (aOR, 0.167; 95% CI, 0.056–0.499). Sensitivity analyses did not change the primary results. Conclusions— In patients presenting with ASPECTS 0–5, who were treated with mechanical thrombectomy, successful reperfusion was beneficial without increasing the risk of symptomatic intracerebral hemorrhage. Although the results do not allow for general treatment recommendations, formal testing of mechanical thrombectomy versus best medical treatment in these patients in a randomized controlled trial is warranted.

scholarly journals Relationship between stroke etiology and collateral status in anterior circulation large vessel occlusion

2020 ◽  
Vol 267 (11) ◽  
pp. 3362-3370
Author(s):  
Eva Hassler ◽  
Markus Kneihsl ◽  
Hannes Deutschmann ◽  
Nicole Hinteregger ◽  
Marton Magyar ◽  
...  
Keyword(s):  
Carotid Artery ◽  
Adverse Events ◽  
Infarct Size ◽  
Artery Occlusion ◽  
Large Vessel ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Extracranial Carotid Artery

Abstract Background and purpose Clinical outcome after mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke is influenced by the intracerebral collateral status. We tested the hypothesis that patients with preexisting ipsilateral extracranial carotid artery stenosis (CAS) would have a better collateral status compared to non-CAS patients. Additionally, we evaluated MT-related adverse events and outcome for both groups. Methods Over a 7-year period, we identified all consecutive anterior circulation MT patients (excluding extracranial carotid artery occlusion and dissection). Patients were grouped into those with CAS ≥ 50% according to the NASCET criteria and those without significant carotid stenosis (non-CAS). Collateral status was rated on pre-treatment CT- or MR-angiography according to the Tan Score. Furthermore, we assessed postinterventional infarct size, adverse events and functional outcome at 90 days. Results We studied 281 LVO stroke patients, comprising 46 (16.4%) with underlying CAS ≥ 50%. Compared to non-CAS stroke patients (n = 235), patients with CAS-related stroke more often had favorable collaterals (76.1% vs. 46.0%). Recanalization rates were comparable between both groups. LVO stroke patients with underlying CAS more frequently had adverse events after MT (19.6% vs. 6.4%). Preexisting CAS was an independent predictor for favorable collateral status in multivariable models (Odds ratio: 3.3, p = 0.002), but post-interventional infarct size and functional 90-day outcome were not different between CAS and non-CAS patients. Conclusions Preexisting CAS ≥ 50% was associated with better collateral status in LVO stroke patients. However, functional 90-day outcome was independent from CAS, which could be related to a higher rate of adverse events.

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