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  • 1
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    Effect of endovascular reperfusion in relation to site of arterial occlusion
    Ovid Technologies (Wolters Kluwer Health) ; 2016
    In:  Neurology Vol. 86, No. 8 ( 2016-02-23), p. 762-770
    Details
    In: Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 86, No. 8 ( 2016-02-23), p. 762-770
    Type of Medium: Online Resource
    ISSN: 0028-3878 , 1526-632X
    URL: Article
    DOI: 10.1212/WNL.0000000000002399
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2016
    detail.hit.zdb_id: 1491874-2
    detail.hit.zdb_id: 207147-2
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  • 2
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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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  • 3
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    Thrombectomy for anterior circulation stroke beyond 6 h from time last known well (AURORA): a systematic review and individual patient data meta-analysis
    Elsevier BV ; 2022
    In:  The Lancet Vol. 399, No. 10321 ( 2022-01), p. 249-258
    Details
    In: The Lancet, Elsevier BV, Vol. 399, No. 10321 ( 2022-01), p. 249-258
    Type of Medium: Online Resource
    ISSN: 0140-6736
    URL: Article
    DOI: 10.1016/S0140-6736(21)01341-6
    RVK:
    XA 10000
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2022
    detail.hit.zdb_id: 3306-6
    SSG: 5,21
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  • 4
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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
    detail.hit.zdb_id: 1467823-8
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  • 5
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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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  • 6
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    Abstract 53: The Malignant MRI profile: Implications for Endovascular Therapy
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  Stroke Vol. 43, No. suppl_1 ( 2012-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 43, No. suppl_1 ( 2012-02)
    Abstract: Background: The Malignant MRI profile identifies stroke patients with poor outcomes and an increased incidence of parenchymal hematoma following iv thrombolysis; outcomes following endovascular reperfusion therapy have not been described. Methods: The NIH funded DEFUSE 2 trial enrolled consecutive acute stroke patients in whom endovascular therapy was anticipated. An MRI scan was obtained immediately prior to intra-arterial reperfusion therapy, then repeated following the procedure and on day 5. Perfusion-weighted (PWI) and diffusion-weighted imaging (DWI) maps were created and lesion volumes estimated with an automated software program (RAPID). In the DEFUSE 2, the Malignant profile was pre-specified as a DWI lesion ≥70mL and/or a PWI lesion based on Tmax 〉 10sec threshold (Tmax 〉 10s) ≥100mL. A receiver operating characteristic (ROC) curve analysis was performed to identify Tmax 〉 10s and DWI volumes that predicted poor outcome (defined as a mRS 5-6 at 30 days) with a high specificity. Patients with an M1 or ICA occlusion who did not undergo endovascular therapy based on local site criteria were also included in the ROC analysis. Results: We report a preliminary analysis of the DEFUSE 2 database (full data will be presented at the meeting). One hundred and one patients were triaged to the cath lab for endovascular therapy. Of the 83 patients who had adequate data available for this analysis, 9 (11%) met the predefined criteria for the Malignant profile. 56% of the Malignant patients had poor outcome compared with 30% of the non-Malignant cases (p=0.14). Malignant patients had an increased risk of parenchymal hematoma (PH1 or PH2): 44% vs. 14% (p=0.04). Only 1 of the Malignant patients achieved a mRS of 0-2 at 30 days. Early reperfusion was obtained in 6 of the 9 Malignant patients but was not associated with an increase in favorable clinical outcome or a decrease in the risk of poor outcome. Fifteen patients with an M1 or ICA occlusion did not undergo endovascular therapy based on local site criteria. Ten of these patients had the Malignant profile and 8 of these 10 had a poor outcome. ROC curve analysis identified a DWI lesion of 112 mL and a Tmax 〉 10s lesion of 116 mL as optimal thresholds to predict poor outcome; both achieved a specificity of 98% and sensitivities of 27% and 24% respectively. 81% (13/16) of the Malignant patients identified by the DWI and/or Tmax 〉 10s optimal thresholds had poor outcome. Conclusion: Patients with large baseline DWI and/or large severe PWI lesions are likely to have poor outcomes with or without endovascular reperfusion therapy. Automated imaging software can identify these patients rapidly.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.43.suppl_1.A53
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
    detail.hit.zdb_id: 80381-9
    detail.hit.zdb_id: 1467823-8
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  • 7
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    MRI profile and response to endovascular reperfusion after stroke (DEFUSE 2): a prospective cohort study
    Elsevier BV ; 2012
    In:  The Lancet Neurology Vol. 11, No. 10 ( 2012-10), p. 860-867
    Details
    In: The Lancet Neurology, Elsevier BV, Vol. 11, No. 10 ( 2012-10), p. 860-867
    Type of Medium: Online Resource
    ISSN: 1474-4422
    URL: Article
    DOI: 10.1016/S1474-4422(12)70203-X
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2012
    detail.hit.zdb_id: 2081241-3
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  • 8
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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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  • 9
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    Abstract 52: Results of DEFUSE 2: Imaging Endpoints
    Ovid Technologies (Wolters Kluwer Health) ; 2012
    In:  Stroke Vol. 43, No. suppl_1 ( 2012-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 43, No. suppl_1 ( 2012-02)
    Abstract: Background: The aim of DEFUSE 2 is to determine if predefined MRI profiles predict clinical and imaging outcomes following endovascular reperfusion therapy. Methods: This prospective, NIH funded, multi-center study enrolled consecutive acute stroke patients in whom an MRI scan could be obtained immediately prior to intra-arterial therapy. A follow-up MRI was performed within 12 hrs of completion of the procedure and again at 5 days. PWI and DWI lesion volumes were determined using a fully automated software program (RAPID). Lesion growth (infarct volume on 5 day FLAIR - baseline DWI volume) was compared for patients with and without the Target mismatch profile based on whether early reperfusion occurred. The Target mismatch profile was defined as PWI(Tmax 〉 6s) / DWI 〉 1.8, DWI 〈 70 mL and PWI(Tmax 〉 10s) 〈 100 mL. Early reperfusion was defined as a 〉 50% reduction in PWI volume following the procedure. The incidence and extent of DWI reversal was assessed and the fate of PWI lesions that were not reperfused was determined. Favorable clinical response was defined as an improvement in NIHSS ≥8 or 0-1 at 30 days. Results: This abstract represents a preliminary analysis of 71 of 101 patients who were treated with endovascular therapy (final results to be presented). Among the 54 patients with Target mismatch, early reperfusion was achieved in 70% and was associated with less infarct growth (relative median growth 210% vs. 450%, p=0.01) and a higher rate of favorable clinical response (OR=5.4; 95%CI 1.5-19.2). In patients without the Target mismatch profile (N= 13) early reperfusion was not associated with a reduction in infarct growth (relative median growth was 220% in both reperfusers and non-reperfusers; p=0.94) or an increased rate of favorable clinical response (OR=0.1; 95%CI 0.004-2.2). 96% of all voxels that were DWI positive at baseline were incorporated into the final infarct (assessed on the co-registered 5 day FLAIR); only 3 of 71 patients had FLAIR volumes that were smaller than the baseline DWI lesion (mean difference 3 mL). 80% of the voxels that had a PWI lesion (Tmax 〉 6s) on the post-procedure scan were incorporated into the final infarct. The correlation between the union of the baseline DWI + early follow-up PWI lesion and the 5 day FLAIR volume was high (r=0.84; p 〈 0.0001). In 82% of the patients, the day 5 FLAIR volume was as at least as large as the union of the baseline DWI + early follow-up PWI lesion. Conclusion: Patients with the Target mismatch profile who achieve early reperfusion following intra-arterial therapy have less infarct growth and more favorable clinical outcomes. In contrast, no benefit of reperfusion was evident for non-Target mismatch patients. Baseline DWI lesions are virtually always fully incorporated into the final infarct volume, regardless of reperfusion. Tissue that remains hypoperfused (Tmax 〉 6s) following endovascular therapy reliably progresses to infarction.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.43.suppl_1.A52
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
    detail.hit.zdb_id: 80381-9
    detail.hit.zdb_id: 1467823-8
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  • 10
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    Abstract TP46: ASPECTS Performance in a Series of Patients Undergoing CT and MRI: Reader Agreement, Modality Agreement, and Outcome Prediction
    Ovid Technologies (Wolters Kluwer Health) ; 2013
    In:  Stroke Vol. 44, No. suppl_1 ( 2013-02)
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 44, No. suppl_1 ( 2013-02)
    Abstract: Objective: To compare the performance of pre-treatment Alberta Stroke Program Early CT scoring (ASPECTS) using NCCT and MRI in a large endovascular therapy cohort. Methods: This is a DEFUSE 2 substudy. Prospectively enrolled patients underwent baseline CT, MRI and started endovascular therapy within 12 hours of stroke onset. Inclusion criteria for this analysis were evaluable pre-treatment NCCT, diffusion-weighted MRI (DWI) and 90-day modified Rankin Scale (mRS) score. Two expert readers graded ischemic change on NCCT and DWI using the ASPECTS and were blinded to all clinical information except stroke side. ASPECTS scores were analyzed either full scale, trichotomized (0-4 vs. 5-7 vs. 8-10), or dichotomized (0-7 vs. 8-10). Good functional outcome was defined as a 90 day mRS of 0-2. Infarct volumes were calculated using rapid processing of perfusion and diffusion (RAPID) software. Results: 71 patients fulfilled our study criteria. Their mean age was 68±15 years, median NIHSS score was 17 (IQR 12-20), and 49% were female. There were 31 (44%) right-sided strokes. Reader and modality agreement are presented in the Table. Median (IQR) time between NCCT and MRI was 1.62 (1.14-2.38) hours. There was greater correlation of DWI ASPECTS with DWI volume (p 〈 0.001) and functional outcome (p=0.001) than NCCT ASPECTS. DWI ASPECTS correlated with 90 day mRS with OR (95%) of: 12.3 (1.4-105) 8-10 vs.0-4; 4.0 (1.2-13.2) 8-10 vs. 5-7; 3.1 (0.3-30) 5-7 vs. 0-4; and 5.4 (1.8-16.2) 8-10 vs.0-7. NCCT ASPECTS did not correlate with mRS with OR (95%) of: 1.4(0.2-8.3) 8-10 vs. 0-4, 1.02(0.4-2.8) 8-10 vs. 5-7, 1.4(0.2-8.5) 5-7 vs. 0-4, and 1.1(0.4-2.9) 8-10 vs. 0-7. Conclusion: Inter-rater agreement on NCCT ASPECTS, as well agreement between NCCT and DWI ASPECTS, ranged from slight to moderate. DWI ASPECTS outperformed NCCT ASPECTS in correlation with DWI volume and predicting functional outcome at 90 days. These results may be influenced by differences in acquisition times for NCCT and MRI.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.44.suppl_1.ATP46
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2013
    detail.hit.zdb_id: 80381-9
    detail.hit.zdb_id: 1467823-8
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