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  • 1
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    Time From Imaging to Endovascular Reperfusion Predicts Outcome in Acute Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2018
    In:  Stroke Vol. 49, No. 4 ( 2018-04), p. 952-957
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 49, No. 4 ( 2018-04), p. 952-957
    Abstract: This study aims to describe the relationship between computed tomographic (CT) perfusion (CTP)-to-reperfusion time and clinical and radiological outcomes, in a cohort of patients who achieve successful reperfusion for acute ischemic stroke. Methods— We included data from the CRISP (Computed Tomographic Perfusion to Predict Response in Ischemic Stroke Project) in which all patients underwent a baseline CTP scan before endovascular therapy. Patients were included if they had a mismatch on their baseline CTP scan and achieved successful endovascular reperfusion. Patients with mismatch were categorized into target mismatch and malignant mismatch profiles, according to the volume of their Tmax 〉 10s lesion volume (target mismatch, 〈 100 mL; malignant mismatch, 〉 100 mL). We investigated the impact of CTP-to-reperfusion times on probability of achieving functional independence (modified Rankin Scale, 0–2) at day 90 and radiographic outcomes at day 5. Results— Of 156 included patients, 108 (59%) had the target mismatch profile, and 48 (26%) had the malignant mismatch profile. In patients with the target mismatch profile, CTP-to-reperfusion time showed no association with functional independence ( P =0.84), whereas in patients with malignant mismatch profile, CTP-to-reperfusion time was strongly associated with lower probability of functional independence (odds ratio, 0.08; P =0.003). Compared with patients with target mismatch, those with the malignant mismatch profile had significantly more infarct growth (90 [49–166] versus 43 [18–81] mL; P =0.006) and larger final infarct volumes (110 [61–155] versus 48 [21–99] mL; P =0.001). Conclusions— Compared with target mismatch patients, those with the malignant profile experience faster infarct growth and a steeper decline in the odds of functional independence, with longer delays between baseline imaging and reperfusion. However, this does not exclude the possibility of treatment benefit in patients with a malignant profile.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.117.018858
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2018
    detail.hit.zdb_id: 80381-9
    detail.hit.zdb_id: 1467823-8
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  • 2
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    Computed tomographic perfusion to Predict Response to Recanalization in ischemic stroke
    Wiley ; 2017
    In:  Annals of Neurology Vol. 81, No. 6 ( 2017-06), p. 849-856
    Details
    In: Annals of Neurology, Wiley, Vol. 81, No. 6 ( 2017-06), p. 849-856
    Abstract: To assess the utility of computed tomographic (CT) perfusion for selection of patients for endovascular therapy up to 18 hours after symptom onset. Methods We conducted a multicenter cohort study of consecutive acute stroke patients scheduled to undergo endovascular therapy within 90 minutes after a baseline CT perfusion. Patients were classified as “target mismatch” if they had a small ischemic core and a large penumbra on their baseline CT perfusion. Reperfusion was defined as 〉 50% reduction in critical hypoperfusion between the baseline CT perfusion and the 36‐hour follow‐up magnetic resonance imaging. Results Of the 201 patients enrolled, 190 patients with an adequate baseline CT perfusion study who underwent angiography were included (mean age = 66 years, median NIH Stroke Scale [NIHSS] = 16, median time from symptom onset to endovascular therapy = 5.2 hours). Rate of reperfusion was 89%. In patients with target mismatch (n = 131), reperfusion was associated with higher odds of favorable clinical response, defined as an improvement of ≥8 points on the NIHSS (83% vs 44%; p  = 0.002, adjusted odds ratio [OR] = 6.6, 95% confidence interval [CI]  = 2.1–20.9). This association did not differ between patients treated within 6 hours (OR = 6.4, 95% CI = 1.5–27.8) and those treated  〉  6 hours after symptom onset (OR = 13.7, 95% CI = 1.4–140). Interpretation The robust association between endovascular reperfusion and good outcome among patients with the CT perfusion target mismatch profile treated up to 18 hours after symptom onset supports a randomized trial of endovascular therapy in this patient population. Ann Neurol 2017;81:849–856
    Type of Medium: Online Resource
    ISSN: 0364-5134 , 1531-8249
    URL: Issue
    URL: Article
    DOI: 10.1002/ana.v81.6
    DOI: 10.1002/ana.24953
    Language: English
    Publisher: Wiley
    Publication Date: 2017
    detail.hit.zdb_id: 80362-5
    detail.hit.zdb_id: 2037912-2
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  • 3
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    Abstract 57: Main Results of the CTP to Predict Response to Recanalization in Ischemic Stroke Project (CRISP)
    Ovid Technologies (Wolters Kluwer Health) ; 2016
    In:  Stroke Vol. 47, No. suppl_1 ( 2016-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 47, No. suppl_1 ( 2016-02)
    Abstract: Background: Recent acute stroke trials showed benefit from intra-arterial thrombectomy (IAT) up to 6 hrs. We aimed to assess CT Perfusion (CTP) for selection of patients for endovascular therapy up to 18 hrs. Hypothesis: CTP target mismatch profile (TMM) identifies patients likely to benefit from IAT. Methods: The CTP to predict Response to recanalization in Ischemic Stroke Project (CRISP) is an NIH funded multicenter cohort study of consecutive acute stroke patients scheduled to undergo IAT within 90 min after a baseline CTP. Volumes for the CTP ischemic core (rCBF 〈 30%) and critically hypoperfused tissue (Tmax 〉 6s) were computed with automated software (RAPID). Target Mismatch (TMM) was defined as a CBF core 〈 70 mL, a Tmax 〉 6s – core difference 〉 15mL, a Tmax 〉 6s : core ratio 〉 1.8, and a Tmax 〉 10s lesion 〈 100 mL. Reperfusion was defined as 〉 50% reduction in Tmax 〉 6s lesion volume between baseline CTP and follow-up MRI (obtained 〈 36 hrs after CTP), or TICI 2b/3 at completion of IAT if follow-up MRI was not performed/technically inadequate. Good functional outcome (GFO) was defined as mRS 0-2 on day 90. Results: Of the 201 patients enrolled, 6 had inadequate baseline CTP (3%), 3 did not undergo angiography, and 2 were lost to follow-up. Therefore, 190 patients were included; mean age 66 yrs, median NIHSS 16, median time from symptom onset to IAT 5.2 hrs ( 〉 6 hrs in 40%). Rate of reperfusion was 89% (87% TICI 2b/3) and 55% had GFO. In patients with TMM (n=131), reperfusion was associated with higher odds of GFO (66% vs 29%; OR=4.3; 95% CI 1.4-13). This association remained significant when adjusted for age and NIHSS (OR=8.4; 95% CI 2.5-28). In patients without TMM (n=51), the effect of reperfusion could not be assessed, since almost all patients (95%) reperfused. Independent of reperfusion status, patients with TMM had a higher rate of GFO (61%) than those without TMM (42%, p=0.02). Conclusion: In this multicenter study, a technically adequate baseline CTP was obtained in nearly all patients and almost half underwent IAT beyond 6 hrs. Patients with the TMM profile had a high rate of GFO (61%) and a robust association between reperfusion and good outcome. These results support the feasibility of a randomized trial of IAT in an extended window using the CTP-TMM profile for patient selection.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.47.suppl_1.57
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2016
    detail.hit.zdb_id: 80381-9
    detail.hit.zdb_id: 1467823-8
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  • 4
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    Assessment of Optimal Patient Selection for Endovascular Thrombectomy Beyond 6 Hours After Symptom Onset : A Pooled Analysis of the AURORA Database
    American Medical Association (AMA) ; 2021
    In:  JAMA Neurology Vol. 78, No. 9 ( 2021-09-01), p. 1064-
    Details
    In: JAMA Neurology, American Medical Association (AMA), Vol. 78, No. 9 ( 2021-09-01), p. 1064-
    Type of Medium: Online Resource
    ISSN: 2168-6149
    URL: Article
    DOI: 10.1001/jamaneurol.2021.2319
    Language: English
    Publisher: American Medical Association (AMA)
    Publication Date: 2021
    detail.hit.zdb_id: 2702023-X
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  • 5
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    Abstract 6: Patient Selection is a Better Predictor of Good Outcome Than Time to Reperfusion in Acute Ischemic Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2016
    In:  Stroke Vol. 47, No. suppl_1 ( 2016-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 47, No. suppl_1 ( 2016-02)
    Abstract: Introduction: Intra-arterial therapy has become standard-of-care for stroke patients with large vessel occlusions presenting within 6 hours of symptom onset. Treatment effectiveness at later times is currently unknown. Using data from the CT Perfusion (CTP) to predict Response to recanalization in Ischemic Stroke Project (CRISP), we assessed the effect of time to treatment on the probability of good outcomes. Hypothesis: Symptom onset-to-reperfusion time is not associated with probability of favorable outcomes in patients with target mismatch who achieve reperfusion. Methods: All patients enrolled underwent baseline CTP. For this analysis, we included data from patients with target mismatch (ratio of Tmax 〉 6s lesion to core volume of 〉 1.8) who achieved endovascular reperfusion. We determined reperfusion status by early follow-up MRI or CTP, or final TICI score 2b-3 if early follow-up perfusion imaging is unavailable. We defined good functional outcome (GFO) as mRS 0-2 at day 90. We assessed the probability of good outcome as a function of onset-to-reperfusion time using logistic regression, with prespecified adjustment for age and baseline NIHSS. Results: Following intra-arterial intervention performed within 18 hours, 102 patients with target mismatch achieved reperfusion. Median onset-to-reperfusion time was 6.6 hours (IQR 5.2-9.5). In univariate analysis, onset-to-reperfusion time was not associated with GFO (p=0.19), whereas age and NIHSS were. Similarly, in multivariate analysis, age and NIHSS were associated with GFO, while onset-to-reperfusion time was not. The adjusted relative risk per hour of delay is 0.994 (95% CI 0.97-1.02). GFO was achieved in 71.4% of patients treated within 6 hours, and in 61.7% of patients treated after 6 hours. Conclusion: The lack of significant association between onset-to-reperfusion time and GFO, and the high proportion of patients achieving good outcomes at 6-18 hours, suggest that endovascular interventions may be beneficial beyond 6 hours with a CTP target mismatch profile, supporting randomized controlled trials of endovascular therapy in the extended time window in selected patients.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.47.suppl_1.6
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2016
    detail.hit.zdb_id: 80381-9
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  • 6
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    Abstract WP34: Associations Between CTP Ischemic Core Volume, ASPECTS Scores and Clinical Outcomes After Endovascular Reperfusion
    Ovid Technologies (Wolters Kluwer Health) ; 2016
    In:  Stroke Vol. 47, No. suppl_1 ( 2016-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 47, No. suppl_1 ( 2016-02)
    Abstract: Introduction: ASPECTS and CT perfusion (CTP) lesion volumes have been used to triage patients with large artery occlusions to endovascular therapy. Specifically, ASPECTS ≤5 and CTP infarct core 〉 50 mL excluded patients from some recent endovascular trials. It is unclear how well these criteria select patients who will have poor functional outcomes despite reperfusion and if the criteria are interchangeable. Hypothesis: ASPECTS and CTP infarct volumes are correlated and both predict clinical outcome. Methods: Patients with anterior circulation strokes were enrolled in a prospective multi-center study (CRISP) if CTP could be obtained 〈 90 minutes before endovascular treatment, and intervention performed 〈 18h from onset. Reperfusion was defined as 〉 50% reduction from baseline Tmax 〉 6s volume on early follow-up MRI ( 〈 36h from baseline CT) or final TICI 2b/3 if follow-up MRI unavailable. A single blinded reader at the core imaging facility determined ASPECTS on baseline CT. Baseline ischemic core volumes were assessed using automated software (RAPID). Good outcome was defined as mRS 0-2 and poor outcome as mRS 5-6. Results: This analysis includes 165 patients with reperfusion after endovascular therapy. Baseline ASPECTS and infarct core volume are inversely associated (p=0.009). Lower ASPECTS and larger infarct core were associated with a lower chance of good outcome in univariate analysis: OR for good outcome was 0.8 (95% CI 0.7-1.0) per point decrease in ASPECTS and 0.8 (95% CI 0.6-0.9) per 10mL increase in infarct core. Adjusted for baseline NIHSS and age, core remained a predictor of good outcomes (p=0.025) while ASPECTS showed a strong trend (p=0.072). The PPV for poor outcome despite reperfusion was 38% (5/13) for infarct core 〉 50 mL and 0% (0/7) for ASPECTS ≤5 (p=0.1 for difference in PPV). No patient met both criteria. Conclusions: The ASPECTS and ischemic core volume criteria used to exclude patients from some endovascular therapy trials, did not agree in identifying patients with presumed poor outcomes. Neither criterion had a high specificity for identifying patients destined to have a poor outcome despite reperfusion. Randomized trials are warranted to assess the efficacy of endovascular therapy in patients with ischemic core lesions 〉 50 ml and ASPECTS ≤5.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.47.suppl_1.wp34
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2016
    detail.hit.zdb_id: 80381-9
    detail.hit.zdb_id: 1467823-8
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  • 7
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    Collateral blood flow measurement with intravoxel incoherent motion perfusion imaging in hyperacute brain stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Neurology Vol. 92, No. 21 ( 2019-05-21)
    Details
    In: Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 92, No. 21 ( 2019-05-21)
    Type of Medium: Online Resource
    ISSN: 0028-3878 , 1526-632X
    URL: Article
    DOI: 10.1212/WNL.0000000000007538
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
    detail.hit.zdb_id: 1491874-2
    detail.hit.zdb_id: 207147-2
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  • 8
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    Contralateral Hemispheric Cerebral Blood Flow Measured With Arterial Spin Labeling Can Predict Outcome in Acute Stroke
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. 12 ( 2019-12), p. 3408-3415
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. 12 ( 2019-12), p. 3408-3415
    Abstract: Imaging is frequently used to select acute stroke patients for intra-arterial therapy. Quantitative cerebral blood flow can be measured noninvasively with arterial spin labeling magnetic resonance imaging. Cerebral blood flow levels in the contralateral (unaffected) hemisphere may affect capacity for collateral flow and patient outcome. The goal of this study was to determine whether higher contralateral cerebral blood flow (cCBF) in acute stroke identifies patients with better 90-day functional outcome. Methods— Patients were part of the prospective, multicenter iCAS study (Imaging Collaterals in Acute Stroke) between 2013 and 2017. Consecutive patients were enrolled after being diagnosed with anterior circulation acute ischemic stroke. Inclusion criteria were ischemic anterior circulation stroke, baseline National Institutes of Health Stroke Scale score ≥1, prestroke modified Rankin Scale score ≤2, onset-to-imaging time 〈 24 hours, with imaging including diffusion-weighted imaging and arterial spin labeling. Patients were dichotomized into high and low cCBF groups based on median cCBF. Outcomes were assessed by day-1 and day-5 National Institutes of Health Stroke Scale; and day-30 and day-90 modified Rankin Scale. Multivariable logistic regression was used to test whether cCBF predicted good neurological outcome (modified Rankin Scale score, 0–2) at 90 days. Results— Seventy-seven patients (41 women) met the inclusion criteria with median (interquartile range) age of 66 (55–76) yrs, onset-to-imaging time of 4.8 (3.6–7.7) hours, and baseline National Institutes of Health Stroke Scale score of 13 (9–20). Median cCBF was 38.9 (31.2–44.5) mL per 100 g/min. Higher cCBF predicted good outcome at day 90 (odds ratio, 4.6 [95% CI, 1.4–14.7]; P =0.01), after controlling for baseline National Institutes of Health Stroke Scale, diffusion-weighted imaging lesion volume, and intra-arterial therapy. Conclusions— Higher quantitative cCBF at baseline is a significant predictor of good neurological outcome at day 90. cCBF levels may inform decisions regarding stroke triage, treatment of acute stroke, and general outcome prognosis. Clinical Trial Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT02225730.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.119.026499
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
    detail.hit.zdb_id: 80381-9
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  • 9
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    Abstract 158: The Malignant CTP Imaging Profile Predicts Worse Functional Outcomes
    Ovid Technologies (Wolters Kluwer Health) ; 2016
    In:  Stroke Vol. 47, No. suppl_1 ( 2016-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 47, No. suppl_1 ( 2016-02)
    Abstract: Introduction: The Malignant MRI profile, defined as a large lesion on DWI or PWI (Tmax 〉 10s), has been proposed as a marker of poor outcome despite reperfusion. It is not known if a corresponding malignant CT perfusion (CTP) profile can be used to identify stroke patients with a poor prognosis despite timely reperfusion. Hypothesis: The Malignant CTP profile identifies stroke patients with poor clinical outcomes despite endovascular reperfusion. Methods: The NIH-funded CTP to predict Response to recanalization in Ischemic Stroke Project (CRISP) prospectively enrolled acute ischemic stroke patients undergoing intra-arterial thrombectomy. CTP was obtained prior to the procedure and followed by a post-procedural MRI within 36 hours. The CTP Malignant profile was pre-specified as an infarct core (rCBF 〈 30%) ≥70mL or a lesion with severe hypoperfusion (Tmax 〉 10s) ≥100mL. Poor functional outcome was defined as a mRS 5-6 at 90 days. We evaluated performance of the pre-specified Malignant CTP profile for predicting poor functional outcome. We then performed an ROC analysis to optimize the ischemic core and Tmax 〉 10s volumes for predicting poor outcome with high specificity (≥90%). Results: Among 190 patients who underwent endovascular therapy, and had technically adequate CTP and 90-day outcome data, 51 (27%) had the Malignant CTP profile (45 on Tmax10 criteria alone, 6 on both infarct core and Tmax10 criteria). The Malignant CTP profile was associated with an increased rate of poor outcome (26% vs 14%; OR = 2.2; 95% CI 0.98-4.8; p=0.08). In patients with reperfusion (n=170), the percent of poor outcomes was significantly higher among patients with the Malignant CTP profile (27% vs 12%, p=0.02; OR = 3.1; 95% CI 1.3-7.4, adjusted for age). Based on ROC analysis, a CTP infarct core 〉 50 mL or a Tmax 〉 10s lesion 〉 150 mL predicted poor outcome with high specificity (90%), but corresponding sensitivity was low (28%) and PPV was modest (36%, or 9/25). Conclusion: Although presence of the Malignant CTP profile doubled the likelihood of poor outcome, only 1 out of 3 patients with this profile who had endovascular reperfusion experienced a poor outcome. This suggests that a subset of patients with the Malignant CTP profile may benefit from endovascular therapy.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.47.suppl_1.158
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2016
    detail.hit.zdb_id: 80381-9
    detail.hit.zdb_id: 1467823-8
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  • 10
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    Hypoperfusion Intensity Ratio Is Correlated With Patient Eligibility for Thrombectomy
    Ovid Technologies (Wolters Kluwer Health) ; 2019
    In:  Stroke Vol. 50, No. 4 ( 2019-04), p. 917-922
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 50, No. 4 ( 2019-04), p. 917-922
    Abstract: Hypoperfusion intensity ratio (HIR) is associated with collateral status in acute ischemic stroke patients with anterior circulation large vessel occlusion. We assessed whether HIR was correlated to patient eligibility for mechanical thrombectomy (MT). Methods— We performed a retrospective cohort study of consecutive acute ischemic stroke patients with a proximal middle cerebral artery or internal carotid artery occlusion who underwent MT triage with computed tomography or magnetic resonance perfusion imaging. Clinical data, ischemic core (mL), HIR (defined as time-to-maximum [TMax] 〉 10 seconds/TMax 〉 6 seconds), mismatch volume between core and penumbra, and MT details were assessed. Primary outcome was favorable HIR collateral score (HIR 〈 0.4) between patients who underwent MT (MT+) and those who did not (MT−) according to American Heart Association guidelines both in the 〈 6 hours and 6 to 24 hours windows. Secondary outcomes were favorable HIR score in MT− subgroups (National Institutes of Health Stroke Scale 〈 6 versus core 〉 70 mL) and core-penumbra mismatch volumes. Patients who did not meet guidelines were not included. Results— We included 197 patients (145 MT+ and 52 MT−). MT+ patients had a significantly lower median HIR compared with MT− patients (0.4 [interquartile range, 0.2–0.5] versus 0.6 [interquartile range, 0.5–0.8] ; P 〈 0.001) and a higher mismatch volume (96 versus 27 mL, P 〈 0.001). Among MT− patients, 43 had a core 〉 70 mL, and 9 had a National Institutes of Health Stroke Scale 〈 6. MT− patients with National Institutes of Health Stroke Scale 〈 6 had a lower HIR than MT− patients with core 〉 70 mL (0.2 [interquartile range, 0.2–0.3] versus 0.7 [interquartile range, 0.6–0.8] , P 〈 0.001) but their HIR was not significantly different that MT+ patients. Conclusions— Patients who meet American Heart Association guidelines for thrombectomy are more likely to have favorable collaterals (low HIR). HIR may be used as a marker of eligibility for MT triage.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.118.024134
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2019
    detail.hit.zdb_id: 80381-9
    detail.hit.zdb_id: 1467823-8
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