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  • 1
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    Abstract 1122‐000084: Does Intravenous Thrombolysis Promote Delayed Reperfusion After Incomplete Mechanical Thrombectomy?
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Stroke: Vascular and Interventional Neurology Vol. 1, No. S1 ( 2021-11)
    Details
    In: Stroke: Vascular and Interventional Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 1, No. S1 ( 2021-11)
    Abstract: Introduction : The value of intravenous thrombolysis (IVT) in patients eligible for mechanical thrombectomy (MT) remains unclear. We hypothesized that pre‐treatment with and/or ongoing IVT may facilitate reperfusion of distal vessel occlusion after incomplete MT. We evaluated this potential association using follow‐up perfusion imaging. Methods : Retrospective observational analysis of our institution`s stroke registry included patients with incomplete reperfusion after MT, admitted between February 1, 2015 and December 8, 2020. Delayed reperfusion (DR) was defined as the absence of a persistent perfusion deficit on contrast‐enhanced perfusion imaging ⁓24h±12h after the intervention. The association between baseline parameters and the occurrence of DR was evaluated using a logistic regression analyses. To account for possible time‐dependent associations of IVT with DR, additional stratification sets were made based on different time windows between IVT start time and final angiography runs. Results : Among the 378 included patients (median age 73.5, 50.8% female), DR occurred in 226 (59.8%). Atrial fibrillation (aOR 2.53 [95% CI 1.34 ‐ 4.90]), eTICI score (aOR 3.79 [95% CI 2.71 ‐ 5.48] per TICI grade increase), and intervention‐to‐follow‐up time (aOR 1.08 [95% CI 1.04 ‐ 1.13] per hour delay) were associated with DR. Dichotomized IVT strata showed no association with DR (aOR 0.75 [95% CI 0.42 ‐ 1.33] ), whereas shorter intervals between IVT start and end of the procedure showed a borderline significant association with DR (OR 2.24 [95% CI 0.98 ‐ 5.43, and OR 2.07 [95% 1.06 – 4.31], for 80 and 100 minutes respectively). Patients with DR had higher rates of functional independence (modified Rankin scale 0–2 at 90 days, DR: 63.3% vs PPD: 38.8%; p 〈 0.01) and longer survival time (at 3 years, DR: 69.2% vs PPD: 45.8%; p = 0.001). Conclusions : There is weak evidence that IVT may favor DR after incomplete MT if the time interval between IVT administration and end of the procedure is short. In general, perfusion follow‐up imaging may constitute a suitable surrogate parameter for evaluating medical rescue strategies after incomplete MT, because a considerable proportion of patients do not experience DR, and there seems to be a close correlation with clinical outcomes.
    Type of Medium: Online Resource
    ISSN: 2694-5746
    URL: Article
    DOI: 10.1161/SVIN.01.suppl_1.000084
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
    detail.hit.zdb_id: 3144224-9
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  • 2
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    Association of Intravenous Thrombolysis with Delayed Reperfusion After Incomplete Mechanical Thrombectomy
    Springer Science and Business Media LLC ; 2023
    In:  Clinical Neuroradiology Vol. 33, No. 1 ( 2023-03), p. 87-98
    Details
    In: Clinical Neuroradiology, Springer Science and Business Media LLC, Vol. 33, No. 1 ( 2023-03), p. 87-98
    Abstract: Treatment of distal vessel occlusions causing incomplete reperfusion after mechanical thrombectomy (MT) is debated. We hypothesized that pretreatment with intravenous thrombolysis (IVT) may facilitate delayed reperfusion (DR) of residual vessel occlusions causing incomplete reperfusion after MT. Methods Retrospective analysis of patients with incomplete reperfusion after MT, defined as extended thrombolysis in cerebral infarction (eTICI) 2a–2c, and available perfusion follow-up imaging at 24 ± 12 h after MT. DR was defined as absence of any perfusion deficit on time-sensitive perfusion maps, indicating the absence of any residual occlusion. The association of IVT with the occurrence of DR was evaluated using a logistic regression analysis adjusted for confounders. Sensitivity analyses based on IVT timing (time between IVT start and the occurrence incomplete reperfusion following MT) were performed. Results In 368 included patients (median age 73.7 years, 51.1% female), DR occurred in 225 (61.1%). Atrial fibrillation, higher eTICI grade, better collateral status and longer intervention-to-follow-up time were all associated with DR. IVT did not show an association with the occurrence of DR (aOR 0.80, 95% CI 0.44–1.46, even in time-sensitive strata, aOR 2.28 [95% CI 0.65–9.23] and aOR 1.53 [95% CI 0.52–4.73] for IVT to incomplete reperfusion following MT timing 〈 80 and 〈 100 min, respectively). Conclusion A DR occurred in 60% of patients with incomplete MT at ~24 h and did not seem to occur more often in patients receiving pretreatment IVT. Further research on potential associations of IVT and DR after MT is required.
    Type of Medium: Online Resource
    ISSN: 1869-1439 , 1869-1447
    URL: Article
    DOI: 10.1007/s00062-022-01186-7
    Language: English
    Publisher: Springer Science and Business Media LLC
    Publication Date: 2023
    detail.hit.zdb_id: 2232347-8
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  • 3
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    Timing Is Brain: The Impact of Endovascular Therapy Start Time on Neurological Outcome
    Elsevier BV ; 2019
    In:  SSRN Electronic Journal
    Details
    In: SSRN Electronic Journal, Elsevier BV
    Type of Medium: Online Resource
    ISSN: 1556-5068
    URL: Article
    DOI: 10.2139/ssrn.3408082
    Language: English
    Publisher: Elsevier BV
    Publication Date: 2019
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  • 4
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    Prediction of delayed reperfusion in patients with incomplete reperfusion following thrombectomy
    SAGE Publications ; 2023
    In:  European Stroke Journal Vol. 8, No. 2 ( 2023-06), p. 456-466
    Details
    In: European Stroke Journal, SAGE Publications, Vol. 8, No. 2 ( 2023-06), p. 456-466
    Abstract: The clinical course of patients with incomplete reperfusion after thrombectomy, defined as an expanded Thrombolysis in Cerebral Infarction (eTICI) score of 2a–2c, is heterogeneous. Patients showing delayed reperfusion (DR) have good clinical outcomes, almost comparable to patients with ad-hoc TICI3 reperfusion. We aimed to develop and internally validate a model that predicts DR occurrence in order to inform physicians about the likelihood of a benign natural disease progression. Patients and methods: Single-center registry analysis including all consecutive, study-eligible patients admitted between 02/2015 and 12/2021. Preliminary variable selection for the prediction of DR was performed using bootstrapped stepwise backward logistic regression. Interval validation was performed with bootstrapping and the final model was developed using a random forests classification algorithm. Model performance metrics are reported with discrimination, calibration, and clinical decision curves. Primary outcome was concordance statistics as a measure of goodness of fit for the occurrence of DR. Results: A total of 477 patients (48.8% female, mean age 74 years) were included, of whom 279 (58.5%) showed DR on 24 follow-up. The model’s discriminative ability for predicting DR was adequate (C-statistics 0.79 [95% CI: 0.72–0.85]). Variables with strongest association with DR were: atrial fibrillation (aOR 2.06 [95% CI: 1.23–3.49] ), Intervention-To-Follow-Up time (aOR 1.06 [95% CI: 1.03–1.10]), eTICI score (aOR 3.49 [95% CI: 2.64–4.73] ), and collateral status (aOR 1.33 [95% CI: 1.06–1.68]). At a risk threshold of R = 30%, use of the prediction model could potentially reduce the number of additional attempts in one out of four patients who will have spontaneous DR, without missing any patients who do not show spontaneous DR on follow-up. Conclusions: The model presented here shows fair predictive accuracy for estimating chances of DR after incomplete thrombectomy. This may inform treating physicians on the chances of a favorable natural disease progression if no further reperfusion attempts are made.
    Type of Medium: Online Resource
    ISSN: 2396-9873 , 2396-9881
    URL: Article
    DOI: 10.1177/23969873231164274
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2023
    detail.hit.zdb_id: 2851287-X
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  • 5
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    Association of Time of Day When Endovascular Therapy for Stroke Starts and Functional Outcome
    Ovid Technologies (Wolters Kluwer Health) ; 2021
    In:  Neurology Vol. 96, No. 8 ( 2021-02-23), p. e1124-e1136
    Details
    In: Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 96, No. 8 ( 2021-02-23), p. e1124-e1136
    Abstract: To investigate the association between endovascular therapy (EVT) start time in acute ischemic stroke (AIS) and midterm functional outcome. Methods This retrospective cohort study included all patients with AIS treated with EVT from 2 stroke center registries from January 2012 to December 2018. The primary outcome was the score on the modified Rankin Scale (mRS) and the utility-weighted mRS (uw-mRS) at 90 days. A proportional odds model was used to calculate the common odds ratio (OR) as a measure of the likelihood that the intervention at a given EVT start time would lead to lower scores on the mRS (shift analysis). Results A total of 1,558 cases were equally allotted into 12 EVT start time periods. The primary outcome favored EVT start times in the morning at 08:00–10:20 and 10:20–11:34 (OR, 0.53; 95% confidence interval [CI], 0.38 to 0.75; p 〈 0.001; OR, 0.62; 95% CI, 0.44 to 0.87; p = 0.006, respectively), while it disfavored EVT start times at the end of the working day at 15:55–17:15 and 18:55–20:55 (OR, 1.47; 95% CI, 1.03–2.09; p = 0.034; OR, 1.49; 95% CI, 1.03–2.15; p = 0.033). Symptom onset to EVT start time was significantly higher and use of IV tissue plasminogen activator significantly lower between 10:20 and 11:34 ( p 〈 0.004 and p = 0.012, respectively). Conclusion EVT for AIS in the morning leads to better midterm functional outcome, while EVT at the end of the work day leads to poorer midterm functional outcome. Difference in baseline factors, standard workflow, and technical efficacy metrics could not be identified as potential mediators of this effect.
    Type of Medium: Online Resource
    ISSN: 0028-3878 , 1526-632X
    URL: Article
    DOI: 10.1212/WNL.0000000000011449
    RVK:
    XA 10000
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2021
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  • 6
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    Evaluation of time-resolved whole brain flat panel detector perfusion imaging using RAPID ANGIO in patients with acute stroke: comparison with CT perfusion imaging
    BMJ ; 2023
    In:  Journal of NeuroInterventional Surgery Vol. 15, No. 4 ( 2023-04), p. 387-392
    Details
    In: Journal of NeuroInterventional Surgery, BMJ, Vol. 15, No. 4 ( 2023-04), p. 387-392
    Abstract: In contrast to conventional CT perfusion (CTP) imaging, flat panel detector CT perfusion (FD-CTP) imaging can be acquired directly in the angiosuite. Objective To evaluate time-resolved whole brain FD-CTP imaging and assess clinically important qualitative and quantitative perfusion parameters in correlation with previously acquired conventional CTP using the new RAPID for ANGIO software. Methods We included patients with internal carotid artery occlusions and M1 or M2 occlusions from six centers. All patients underwent mechanical thrombectomy (MT) with preinterventional conventional CTP and FD-CTP imaging. Quantitative performance was determined by comparing volumes of infarct core, penumbral tissue, and mismatch. Eligibility for MT according to the perfusion imaging criteria of DEFUSE 3 was determined for each case from both conventional CTP and FD-CTP imaging. Results A total of 20 patients were included in the final analysis. Conventional relative cerebral blood flow (rCBF) 〈 30% and FD-CTP rCBF 〈 45% showed good correlation (R 2 =0.84). Comparisons of conventional CTP Tmax 〉 6 s versus FD-CTP Tmax 〉 6 s and CTP mismatch versus FD-CTP mismatch showed more variability (R 2 =0.57, and R 2 =0.33, respectively). Based on FD-CTP, 16/20 (80%) patients met the inclusion criteria for MT according to the DEFUSE 3 perfusion criteria, in contrast to 18/20 (90%) patients based on conventional CTP. The vessel occlusion could be correctly extrapolated from the hypoperfusion in 18/20 cases (90%). Conclusions In our multicenter study, time-resolved whole brain FD-CTP was technically feasible, and qualitative and quantitative perfusion results correlated with those obtained with conventional CTP.
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/neurintsurg-2021-018464
    Language: English
    Publisher: BMJ
    Publication Date: 2023
    detail.hit.zdb_id: 2506028-4
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  • 7
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    Association of the 24‐Hour National Institutes of Health Stroke Scale After Mechanical Thrombectomy With Early and Long‐Term Survival
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Stroke: Vascular and Interventional Neurology Vol. 2, No. 4 ( 2022-07)
    Details
    In: Stroke: Vascular and Interventional Neurology, Ovid Technologies (Wolters Kluwer Health), Vol. 2, No. 4 ( 2022-07)
    Abstract: The National Institutes of Health Stroke Scale (NIHSS) obtained 24 hours after ischemic stroke is a good indicator for functional outcome and early mortality, but the correlation with long‐term survival is less clear. We analyzed the correlation of the NIHSS after 24 hours (24h NIHSS) and early clinical neurological development after mechanical thrombectomy with early and long‐term survival as well as its predictive power on survival. Methods We reviewed a prospective observational registry for all patients undergoing mechanical thrombectomy between January 2010 and December 2018. Vital status was extracted from the Swiss Population Registry. Adjusted hazard ratio (aHR) and crude hazard ratios were calculated using Cox regression. To assess predictive power of the 24h NIHSS, different Random Survival Forest models were evaluated. Results We included 957 patients (median follow‐up 1376 days). Patients with lower 24h NIHSS and major early neurological improvement had substantially better survival rates. We observed significantly higher aHR for death in patients with 24h NIHSS 12 to 15 (aHR, 1.78; 95% CI, 1.1–2.89), with 24h NIHSS 16 to 21 (aHR, 2.54, 95% CI, 1.59–4.06), and with 24h NIHSS 〉 21 (aHR, 5.74; 95% CI, 3.47–9.5). The 24h NIHSS showed the best performance predicting mortality (receiver operating characteristic area under the curve at 3 months [0.85±0.034], at 1 year [0.82±0.029] , at 2 years [0.82±0.031], and at 5 years [0.83±0.035] ), followed by NIHSS change. Conclusions Patients with acute ischemic stroke achieving a low 24h NIHSS or major early neurological improvement after mechanical thrombectomy had markedly lower long‐term mortality. Furthermore, 24h NIHSS had the best predictive power for early and long‐term survival in our machine learning–based prediction.
    Type of Medium: Online Resource
    ISSN: 2694-5746
    URL: Article
    DOI: 10.1161/SVIN.121.000244
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
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  • 8
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    Connecting the DOTs: a novel imaging sign on flat-panel detector CT indicating distal vessel occlusions after thrombectomy
    BMJ ; 2024
    In:  Journal of NeuroInterventional Surgery
    Details
    In: Journal of NeuroInterventional Surgery, BMJ
    Abstract: Immediate non-contrast post-interventional flat-panel detector CT (FPDCT) has been suggested as an imaging tool to assess complications after endovascular therapy (EVT). We systematically investigated a new imaging finding of focal hyperdensities correlating with remaining distal vessel occlusion after EVT. Methods A single-center retrospective analysis was conducted for all acute ischemic stroke patients admitted between July 2020 and December 2022 who underwent EVT and immediate post-interventional FPDCT. A blinded core lab performed reperfusion grading on post-interventional digital subtraction angiography (DSA) images and evaluated focal hyperdensities on FPDCT (here called the distal occlusion tracker (DOT) sign). DOT sign was defined as a tubular or punctiform, vessel confined, hyperdense signal within the initial occlusion target territory. We assessed sensitivity and specificity of the DOT sign when compared with DSA findings. Results The median age of the cohort (n=215) was 74 years (IQR 63–82) and 58.6% were male. The DOT sign was positive in half of the cohort (51%, 110/215). The DOT sign had high specificity (85%, 95% CI 72% to 93%), but only moderate sensitivity (63%, 95% CI 55% to 70%) for detection of residual vessel occlusions. In comparison to the core lab, operators overestimated complete reperfusion in a quarter of the entire cohort (25%, 53/215). In more than half of these cases (53%, 28/53) there was a positive DOT sign, which could have mitigated this overestimation. Conclusion The DOT sign appears to be a frequent finding on immediate post-interventional FPDCT. It correlates strongly with incomplete reperfusion and indicates residual distal vessel occlusions. In the future, it may be used to complement grading of reperfusion success and may help mitigating overestimation of reperfusion in the acute setting.
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/jnis-2023-021218
    Language: English
    Publisher: BMJ
    Publication Date: 2024
    detail.hit.zdb_id: 2506028-4
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  • 9
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    Association of reperfusion success and emboli in new territories with long term mortality after mechanical thrombectomy
    BMJ ; 2022
    In:  Journal of NeuroInterventional Surgery Vol. 14, No. 4 ( 2022-04), p. 326-332
    Details
    In: Journal of NeuroInterventional Surgery, BMJ, Vol. 14, No. 4 ( 2022-04), p. 326-332
    Abstract: The degree of reperfusion is the most important modifiable predictor of 3 month functional outcome and mortality in ischemic stroke patients treated with mechanical thrombectomy. Whether the beneficial effect of reperfusion also leads to a reduction in long term mortality is unknown. Methods Patients undergoing mechanical thrombectomy between January 2010 and December 2018 were included. The post-thrombectomy degree of reperfusion and emboli in new territories were core laboratory adjudicated. Reperfusion was evaluated according to the expanded Thrombolysis in Cerebral Infarction (eTICI) scale. Vital status was obtained from the Swiss population register. Adjusted hazard ratios (aHRs) using time split Cox regression models were calculated. Subgroup analyses were performed in patients with borderline indications. Results Our study included 1264 patients (median follow-up per patient 2.5 years). Patients with successful reperfusion had longer survival times, attributable to a lower hazard of death within 0–90 days and for 〉 90 days to 2 years (aHR 0.34, 95% CI 0.26 to 0.46; aHR 0.37, 95% CI 0.22 to 0.62). This association was homogeneous across all predefined subgroups (p for interaction 〉 0.05). Among patients with successful reperfusion, a significant difference in the hazard of death was observed between eTICI2b50 and eTICI3 (aHR 0.51, 95% CI 0.33 to 0.79). Emboli in new territories were present in 5% of patients, and were associated with increased mortality (aHR 2.3, 95% CI 1.11 to 4.86). Conclusion Successful, and ideally complete, reperfusion without emboli in new territories is associated with a reduction in long term mortality in patients treated with mechanical thrombectomy, and this was evident across several subgroups.
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/neurintsurg-2021-017422
    Language: English
    Publisher: BMJ
    Publication Date: 2022
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  • 10
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    Data_Sheet_1.pdf
    Frontiers Media SA ; 2022
    In:  Frontiers in Neurology Vol. 13 ( 2022-8-3)
    Details
    In: Frontiers in Neurology, Frontiers Media SA, Vol. 13 ( 2022-8-3)
    Abstract: 40% of acute ischemic stroke patients treated by mechanical thrombectomy (MT) have a clinical history of atrial fibrillation (AF). The safety of bridging intravenous thrombolysis (IVT) (MT + IVT) is currently being discussed. We aimed to analyze the interaction between oral anticoagulation (OAC) status or AF with bridging IVT, regarding the occurrence of symptomatic intracranial hemorrhage (sICH) and functional outcome. Materials and Methods Multicentric observational cohort study (BEYOND-SWIFT registry) of consecutive patients undergoing MT between 2010 and 2018 ( n = 2,941). Multinomial regression models were adjusted for prespecified baseline and plausible pathophysiological covariates identified on a univariate analysis to assess the association of AF and OAC status with sICH and good outcomes (90-day modified Rankin Scale score 0–2). Results In the total cohort (median age 74, 50.6% women), 1,347 (45.8%) patients had AF. Higher admission National Institutes of Health Stroke Scale (NIHSS) score (aOR 1.04 [95% 1.02–1.06], per point of increase) and prior medication with Vitamin K antagonists (VKA) (aOR 2.19 [95% 1.27–3.66] ) were associated with sICH. Neither AF itself (aOR 0.71 [95% 0.41–1.24]) nor bridging IVT (aOR 1.08 [0.67–1.75] ) were significantly associated with increased sICH. Receiving bridging IVT (aOR 1.61 [95% 1.24–2.11]) was associated with good 90-day outcome, with no interaction between AF and IVT ( p = 0.92). Conclusion Bridging IVT appears to be a reasonable clinical option in selected patients with AF. Given the increased sICH risk in patients with VKA, subgroup analysis of the randomized controlled trials should analyze whether patients with VKA might benefit from withholding bridging IVT. Registration clinicaltrials.gov ; Unique identifier: NCT03496064.
    Type of Medium: Online Resource
    ISSN: 1664-2295
    URL: Article
    URL: Article
    DOI: 10.3389/fneur.2022.945338
    DOI: 10.3389/fneur.2022.945338.s001
    Language: Unknown
    Publisher: Frontiers Media SA
    Publication Date: 2022
    detail.hit.zdb_id: 2564214-5
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