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  • 11
    Online Resource
    Online Resource
    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
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  • 12
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    Mechanical Thrombectomy in the Late Presentation of Anterior Circulation Large Vessel Occlusion Stroke: A Guideline From the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Committee
    Ovid Technologies (Wolters Kluwer Health) ; 2023
    In:  Stroke: Vascular and Interventional Neurology Vol. 3, No. 1 ( 2023-01)
    Details
    In: Stroke: Vascular and Interventional Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 3, No. 1 ( 2023-01)
    Abstract: Recent clinical trials investigating endovascular therapy in the extended time window have opened new treatment paradigms for patients with late‐presenting large vessel occlusion stroke. The aim of this guideline is to provide up‐to‐date recommendations for the diagnosis, selection, and medical or endovascular treatment of patients with large vessel occlusion presenting in the extended time window. Methods The Society of Vascular and Interventional Neurology Guidelines and Practice Standards committee assembled a writing group and recruited interdisciplinary experts to review and evaluate the current literature. Recommendations were assigned by the writing group using the Society of Vascular and Interventional Neurology Guidelines and Practice Standards Class of Recommendation/Level of Evidence algorithm and Society of Vascular and Interventional Neurology Guidelines and Practice Standards guideline format. The final guideline was approved by all members of the writing group, the Guidelines and Practice Standards committee, and the Society of Vascular and Interventional Neurology board of directors. Results Literature review yielded 3 high‐quality randomized trials and several observational studies that have been extracted to derive the enclosed summary recommendations. In patients with large vessel occlusion presenting in the 6‐ to 24‐hour window and with clinical–imaging mismatch as defined by the DAWN (Diffusion‐Weighted Imaging or Computed Tomography Perfusion Assessment With Clinical Mismatch in the Triage of Wake‐Up and Late Presenting Strokes Undergoing Neurointervention With Trevo) and DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke) studies, endovascular therapy is recommended. Noncontrast computed tomography can be used to evaluate infarct size as the sole imaging modality for patient selection, particularly when access to computed tomography perfusion or magnetic resonance imaging is limited or if their performance would incur substantial delay to treatment. In addition, several clinical questions were reviewed based on the available evidence and consensus grading. Conclusions These guidelines provide practical recommendations based on recent evidence on the diagnosis, selection, and treatment of patients with large vessel occlusion stroke presenting in the extended time window.
    Type of Medium: Online Resource
    ISSN: 2694-5746
    URL: Article
    DOI: 10.1161/SVIN.122.000512
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2023
    detail.hit.zdb_id: 3144224-9
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  • 13
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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: 1467823-8
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  • 14
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    How to Establish the Outer Limits of Reperfusion Therapy
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Stroke Vol. 52, No. 10 ( 2021-10), p. 3399-3403
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 52, No. 10 ( 2021-10), p. 3399-3403
    Abstract: Reperfusion therapy with intravenous alteplase and endovascular therapy are effective treatments for selected patients with acute ischemic stroke. Guidelines for treatment are based upon randomized trials demonstrating substantial treatment effects for highly selected patients based on time from stroke onset and imaging features. However, patients beyond the current established guidelines might benefit with lesser but still clinically significant treatment effects. The STAIR (Stroke Treatment Academic Industry Roundtable) XI meeting convened a workgroup to consider the “outer limits” of reperfusion therapy by defining the current boundaries, and exploring optimal parameters and methodology for determining the outer limits. In addition to statistical significance, the minimum clinically important difference should be considered in exploring the limits of reperfusion therapy. Societal factors and quality of life considerations should be incorporated into assessment of treatment efficacy. The threshold for perception of benefit in the medical community may differ from that necessary for the Food and Drug Administration approval. Data from alternative sources such as platform trials, registries and large pragmatic trials should supplement randomized controlled trials to improve generalizability to routine clinical practice. Further interactions between industry and academic centers should be encouraged.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.121.035022
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 15
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    Endovascular thrombectomy in patients with large core ischemic stroke: a cost-effectiveness analysis from the SELECT study
    BMJ ; 2021
    In:  Journal of NeuroInterventional Surgery Vol. 13, No. 10 ( 2021-10), p. 875-882
    Details
    In: Journal of NeuroInterventional Surgery, BMJ, Vol. 13, No. 10 ( 2021-10), p. 875-882
    Abstract: It is unknown whether endovascular thrombectomy (EVT) is cost effective in large ischemic core infarcts. Methods In the prospective, multicenter, cohort study of imaging selection study (SELECT), large core was defined as computed tomography (CT) ASPECTS 〈 6 or computed tomography perfusion (CTP) ischemic core volume (rCBF 〈 30%) ≥50 cc. A Markov model estimated costs, quality-adjusted life years (QALYs) and the incremental cost-effectiveness ratio (ICER) of EVT compared with medical management (MM) over lifetime. The willingness to pay (WTP) per QALY was set at $50 000 and $100 000 and the net monetary benefits (NMB) were calculated. Probabilistic sensitivity analysis (PSA) and cost-effectiveness acceptability curves (CEAC) for EVT were assessed in SELECT and other pivotal trials. Results From 361 patients enrolled in SELECT, 105 had large core on CT or CTP (EVT 62, MM 43). 19 (31%) EVT vs 6 (14%) MM patients achieved modified Rankin Scale (mRS) score 0–2 (OR 3.27, 95% CI 1.11 to 9.62, P=0.03) with a shift towards better mRS (cOR 2.12, 95% CI 1.05 to 4.31, P=0.04). Over the projected lifetime of patients presenting with large core, EVT led to incremental costs of $33 094 and a gain of 1.34 QALYs per patient, resulting in ICER of $24 665 per QALY. EVT has a higher NMB compared with MM at lower (EVT -$42 747, MM -$76 740) and upper (EVT $155 041, MM $57 134) WTP thresholds. PSA confirmed the results and CEAC showed 77% and 92% acceptability of EVT at the WTP of $50 000 and $100 000, respectively. EVT was associated with an increment of $29 225 in societal costs. The pivotal EVT trials (HERMES, DAWN, DEFUSE 3) were dominant in a sensitivity analysis at the same inputs, with societal cost-savings of $37 901, $86 164 and $22 501 and a gain of 1.62, 2.36 and 2.21 QALYs, respectively. Conclusions In a non-randomized prospective cohort study, EVT resulted in better outcomes in large core patients with higher QALYs, NMB and high cost-effectiveness acceptability rates at current WTP thresholds. Randomized trials are needed to confirm these results. Clinical trial registration NCT02446587
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/neurintsurg-2020-016766
    Language: English
    Publisher: BMJ
    Publication Date: 2021
    detail.hit.zdb_id: 2506028-4
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  • 16
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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
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  • 17
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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
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  • 18
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    Alberta Stroke Program Early Computed Tomographic Scoring Performance in a Series of Patients Undergoing Computed Tomography and MRI : Reader Agreement, Modality Agreement, and Outcome Prediction
    Ovid Technologies (Wolters Kluwer Health) ; 2015
    In:  Stroke Vol. 46, No. 2 ( 2015-02), p. 407-412
    Details
    In: Stroke, Ovid Technologies (Wolters Kluwer Health), Vol. 46, No. 2 ( 2015-02), p. 407-412
    Abstract: In this study, we compare the performance of pretreatment Alberta Stroke Program Early Computed Tomographic scoring (ASPECTS) using noncontrast CT (NCCT) and MRI in a large endovascular therapy cohort. Methods— Prospectively enrolled patients underwent baseline NCCT and MRI and started endovascular therapy within 12 hours of stroke onset. Inclusion criteria for this analysis were evaluable pretreatment NCCT, diffusion-weighted MRI (DWI), and 90-day modified Rankin Scale scores. Two expert readers graded ischemic change on NCCT and DWI using the ASPECTS. ASPECTS scores were analyzed with the full scale or were trichotomized (0–4 versus 5–7 versus 8–10) or dichotomized (0–7 versus 8–10). Good functional outcome was defined as a 90-day modified Rankin Scale score of 0 to 2. Results— Seventy-four patients fulfilled our study criteria. The full-scale inter-rater agreement for CT-ASPECTS and DWI-ASPECTS was 0.579 and 0.867, respectively. DWI-ASPECTS correlated with functional outcome ( P =0.004), whereas CT-ASPECTS did not ( P =0.534). Both DWI-ASPECTS and CT-ASPECTS correlated with DWI volume. The receiver operating characteristic analysis revealed that DWI-ASPECTS outperformed both CT-ASPECTS and the time interval between symptom onset and start of the procedure for predicting good functional outcome (modified Rankin Scale score, ≤2) and DWI volume ≥70 mL. Conclusion— Inter-rater agreement for DWI-ASPECTS was superior to that for CT-ASPECTS. DWI-ASPECTS outperformed NCCT ASPECTS for predicting functional outcome at 90 days.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/STROKEAHA.114.006564
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2015
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  • 19
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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
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  • 20
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    Abstract 135: Correlation of TICI Reperfusion with MR Reperfusion, Infarct Growth and Clinical Outcome in the DEFUSE 2 Trial
    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 Thrombolysis In Cerebral Infarction (TICI) score is a widely used angiographic score in endovascular stroke studies. Assessment of reperfusion based on perfusion weighted MRI (PWI reperfusion) has been used more commonly in patients treated with intravenous thrombolysis. This analysis of the DEFUSE 2 study data was undertaken to 1) determine the association between TICI and PWI reperfusion and 2) assess the association between TICI-reperfusion and clinical and radiographic outcomes. Methods: Patients undergoing acute endovascular stroke therapy of anterior circulation strokes were enrolled in a prospective multi-center study (DEFUSE 2) if an MRI could be obtained within 90 minutes before endovascular treatment and repeated within 12 hours after the intervention. Only patients with a TICI score of 0 or 1 on baseline digital subtraction angiography (DSA) were included in this analysis. A single blinded reader at the core imaging facility determined pre- and post-procedure TICI scores. TICI-reperfusion was defined as a TICI score of 2B or 3. PWI lesion volumes were assessed using fully automated software (RAPID). PWI-reperfusion was defined as a reduction in PWI(Tmax 〉 6s) lesion volume of 〉 50% between baseline and early follow-up. Infarct growth was defined as the difference between baseline DWI and 5-day FLAIR lesion volume. Favorable clinical response was defined as a NIHSS score of 0-1 at day 30 or an improvement in NIHSS score of ≥8 points between baseline and day 30. Results: This preliminary analysis includes 68 of 101 patients who underwent endovascular therapy and had adequate PWI data to assess reperfusion (final results will be presented at the meeting). At completion of endovascular treatment 30% of the patients remained TICI 0 or 1, 27% improved to TICI 2A, 29% to TICI 2B, and 13% had complete reperfusion (TICI 3). Better TICI-reperfusion scores were associated with higher rates of reperfusion assessed by PWI. PWI-reperfusion was seen in 32% of patients who remained TICI 0-1, 53% with TICI 2A, 98% with TICI 2B, and 100% with TICI 3 reperfusion. Agreement between TICI-reperfusion and PWI-reperfusion was moderate (kappa 0.51). The incidence of favorable clinical response increased with higher TICI scores: 35% with TICI 0-1, 44% with TICI 2A, 72% with TICI 2B, and 67% with TICI 3. Patients who met pre-specified DEFUSE 2 criteria for reperfusion (TICI 2B/3) were more likely to have a favorable clinical response (70% vs 40%; p=0.015), and had less median [IQR] lesion growth (10 [2-56] ml vs 67 [28-122] ml; p=0.001) than patients without TICI-reperfusion. Conclusion: TICI 2B or 3 reperfusion following endovascular therapy for acute anterior circulation stroke is highly correlated with PWI reperfusion. Patients with TICI 2B or 3 reperfusion show less infarct growth and are more likely to have a favorable clinical response.
    Type of Medium: Online Resource
    ISSN: 0039-2499 , 1524-4628
    URL: Article
    DOI: 10.1161/str.43.suppl_1.A135
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2012
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